Attuned Consent; Birth Doulas, Care, and the Politics of Consent

Abstract

Doulas—birth practitioners without medical responsibility who provide support to birthing people—have become popular over the past few decades. Drawing from two years of ethnographic research in the United States during which I trained and practiced as a doula, I argue that they are “consent workers” who do complex emotional labor to facilitate the consenting voice of their client. In effect, doulas serve as a bridge between the intimate care and support for choice-making associated with American midwifery before its professionalization and the “informed consent” of medical institutions and contract law. They do so via what I describe as “attuned consent,” which acknowledges ambiguity and complexity, is highly embodied, and is noncoercive without presuming equality. This draws attention to the limits of conventional, defensive models of consent, calling the paradigm of consent into question even as it draws from it to accomplish its work. Attuned consent can shed light on why the rather strange hybrid figure of the doula evolved in this historical moment. It can also provide a productive reflection of other contemporary cultural studies critiques of consent, notably Joseph Fischel's discussion of the limits of sexual consent and Audra Simpson's analysis of Indigenous refusal to either consent to or resist fundamentally hostile relations.

We had covered the clock in the hospital room with a towel, so the creeping of the hours would only have our bodies as witness. I could still hear its metronomic ticking if I listened very carefully. But without the numbers to glance at, we were in a timeless cocoon, one that smelled like sweat, in which my eyelids kept drooping. How many hours had it been since I drove through the dark to meet Brynna at the San Francisco Kaiser hospital? I had left my dinner table, packing some poppyseed cake and grabbing a yellow rose from the jar of flowers. Brynna had eaten the cake gratefully while we waited in the triage room to see if she was advanced enough in her labor to be admitted. She wasn’t. But we brought the rose back to her house, and through the night of intermittent contractions, she used it as a meditation object, something to focus her gaze on, breathing through wave after painful wave.

The next day we walked outside through hillside gardens, trudging up and down flight after flight of the charming steps San Francisco is known for. Every so often I held her upright while she absorbed the gnawing intensity of a contraction, and in between I told her the names and uses of some plants we passed, which I had learned from my dad, and she took an interest in them, glad for the distraction. We attempted napping in the afternoon, an intermittent success. Eventually we made it back to the hospital, rose still in tow, dusk settling, contractions coming one on top of the other. By now, we were well into the second night. And as I said, I could barely keep my eyes open. But despite the sinking rock of my tired body, despite knowing I would be a better doula if I would just take a nap, I couldn’t bring myself to leave Brynna to her pain.

In a different time, a different world, we had discussed what kind of birth she wanted. She had been adamant that she didn’t want an epidural, because the idea of it frightened her—the enormous needle, the dissociation from her body. Needles frightened her more than pain, so she wanted to know what was in my “bag of tricks” to manage pain. By this time, my bag of tricks had gotten us through well over twenty-four hours of labor, but it was nearing the end of its usefulness. When the nurse offered Brynna some fentanyl, a painkilling drug, saying it would take the edge off so both of us could nap before transition and the pushing phase, it was pretty appealing. Brynna was far more exhausted than I was—she had entered a zone of abject bodily endurance. She swiveled her eyes toward me, blankly pleading to not have to rise to the occasion of making this decision.

I knew she wasn’t opposed to medication per se. I knew fentanyl can cause variability in fetal heart rate and “maternal dysphoria.” I knew she aspired to birth vaginally. I knew there was a complicated calculation weighing the “cas-cade of interventions” against the value of rest in making vaginal birth likely.¹ I knew she would need me to be alert more and more acutely as labor progressed. Yes, I said, it sounded like a good idea, because rest would help us both in the long run. Brynna nodded, closing her eyes and rolling inward as another contraction flooded her. I looked up at the nurse, nodding our consent with a brief smile.

Introduction: Doulas As Consent Workers

The birth room is a difficult situation in which to “give consent.” I learned this over nearly three years of anthropological fieldwork in the birth culture of the California Bay Area (2013–16), during which I trained and practiced as a doula, a birth practitioner who provides emotional, physical, and informational support but does not carry legal medical responsibility. Birth typically involves many interactions that could be thought to require consent: viewing the naked body, touching genitals and intimate parts, performing medical procedures, and inviting strangers in to do or witness such things. I argue that doulas, relative newcomers on the scene of birth practitioners, can be considered “consent workers,” among whose primary duties is facilitating the consenting voice of their client. Such an approach is rooted in the relationship between consent and care, which are inextricably linked in the history of women's health activism that gave rise to doulas.² In effect, doulas serve as a bridge between the intimate care and support for choice-making associated with American midwifery before its professionalization and the “informed consent” of medical institutions and contract law. They do so via what I describe as “attuned consent,” which acknowledges ambiguity and complexity, is highly embodied, and is noncoercive without presuming equality.

Doula work is situated within the deeply stratified terrain of medicalized American birth. Over 99 percent of US births take place in the hospital, and only around 8 percent of US hospital births are attended by a midwife (in which case the midwife generally practices under physician purview). American childbirth is thoroughly embedded within regimes of medical oversight, and this is accompanied by undeniable power differentials between patient and physician. Indeed, the entire obstetric hospital space and its personnel are oriented around furthering medical protocols and incentives, which only recently have come under the rubrics of evidence-based medicine.³ Furthermore, American medicine has deep roots in racist and misogynist practices, especially within gynecology and obstetrics.⁴ Scholars of reproductive justice have analyzed the politics of “stratified reproduction,” by which the reproduction of some people is supported while that of others is actively discouraged, within medical systems and social systems more broadly.⁵ The hospital birth room is thus hardly a neutral space in which the consent-giving, rights-bearing liberal subject can be taken for granted.

In my fieldwork as a doula, I did not attend any home births, although I spoke with people who had or were planning to give birth at home. I practiced largely (though not exclusively) among white, middle-class communities aligned with my own demographics. Brynna (a pseudonym) fell into this category, and I take this subject position as a starting point. As difficult as it can be for such birthing people to effectively navigate “consent,” even when privileged to be accompanied by a doula, it is far more difficult when also working against subtle and overt manifestations of racism and classism both within the structure of maternity systems and within the dispositions of hospital staff.⁶ The same holds true for discrimination on grounds of ability, gender normativity, or sexuality.

In what follows, I contextualize my claims about doulas bridging midwifery care and institutionalized consent, develop the attuned consent framework, and then discuss implications, limitations, and power dynamics surrounding it. Attuned consent can shed light on why the rather strange hybrid figure of the doula evolved in this historical moment. It can also provide a productive reflection of other contemporary cultural studies critiques of consent, notably Joseph Fischel's discussion of #MeToo and the limits of sexual consent and Audra Simpson's analysis of Indigenous refusal to either consent to or resist fundamentally hostile settler-colonial relations.⁷

Midwifery and Informed Choice

Since the 1970s, childbirth reform and activism that seek to improve the American maternity care system have challenged medical authority and the medicalization of the birthing space. Most visibly, these changes took place through the resurrection of white midwifery and the “natural birth” movement.⁸ In nonwhite communities, community midwifery was present until more recently, and historical exclusion from medical care produced a different relationship to institutional medical spaces.⁹ Birth activists of color are likewise reclaiming traditions and contesting medicalization.¹⁰ In the 1990s American midwifery underwent professionalization and gained access to hospitals, a controversial movement among midwives, as it greatly limited their autonomy and ability to spend time caring for birthing people. As one midwife explained to me at the Midwives Association of North America (MANA) conference in 2012, though, the tradeoff of being involved in (and hopefully improving) so many more births seemed worth it.

In the wake of midwifery's professionalization, doulas evolved as supplementary providers who play a key role in improving maternity care.¹¹ Their services are not covered by health insurance or regulated in any systematic way (though there are a variety of certification bodies unaffiliated with hospitals), so they retain “outsider” status. Somewhat paradoxically, they exist as both a niche commodity for bespoke care among the relatively privileged, and an activist platform for birth reform among marginalized communities. As such, doulas represent both the privatization of health care within neoliberal transformations of public welfare and grassroots activist pushback against an already privatized, racist, classist, and ineffectual maternity system.¹² Questions of access and oversight are central to deciding what the doula is or should be and are actively being worked out in doula communities.

In many ways, doulas take on the role of care held by informal midwifery and help “translate” it into hospital spaces. In her 2018 piece based on long-standing fieldwork with midwives and “natural birth” in North America, Margaret MacDonald sets out the difference between informed choice, which was a key value in the women's health movement of the 1970s (supported by the publication of the book Our Bodies, Ourselves), and informed consent, which is a biomedical principle. Informed choice must take place within contexts of care and mutuality, whereas informed consent offers a patient the option to say yes or no within an intensely hierarchical context. MacDonald explains how choice was always important to midwifery because it was something that had been denied women in hospitals, but it did not dominate midwifery's self-definition or practice in the early days; it was merely one aspect of the broader cultural project to “reshape women's gendered expectations of pregnancy and birth and rehabilitate their bodies and selves as women and mothers.”¹³ Choice was implicit. Making it explicit was a strategic bridge into mainstream professionalization, a unifying and codifying concept among midwives that was also palatable to “the powers that be” when pitched using the logic of women as consumers with a desire for change and a right to choose it. Yet the rhetoric of consumer choice and rights bypassed midwifery's fundamental concern for women's embodied knowledge and desire to dismantle the doctor-patient hierarchy.

So, MacDonald continues, over the past twenty years the once radical concept of informed choice has become mainstream, understood as the ultimate version of informed consent in some government and industry policy documents. Yet within midwifery, informed choice is not simply an improved version of informed consent. Informed consent is fundamentally an ethical-legal principle whose origins lie within clinical medicine and biomedical research, oriented around liability, whereas informed choice is an inherently politicized notion that was never meant as an add-on to clinical care but deeply embedded in a fundamentally different model of care from which it was never meant to be extracted. Midwifery care was about time and relationships of mutual trust and respect between midwives and clients, the hard-to-codify container in which expertise, information, experience, and choice were mixed. In the social movement of midwifery, choice is impossible without care, and care is unthinkable without choice.

As midwifery became medicalized and constrained by hospital norms like tight schedules and the prioritization of liability, I see doulas as having evolved to fill this void of personalized care, trust, and shared decision-making. The approach of doulas I encountered has much in common with the partnership model MacDonald describes as informed choice, as opposed to the hierarchical doctor-patient model of clinical informed consent. That is, doulas combine biomedical information with women's own experience to encourage their knowledge and sense of empowerment regarding their health care; consider the client as lay expert on her own body, not just as a health consumer with options; and have the client's autonomy as the ultimate goal, which is understood to only be possible through a “relational approach.” Lastly, like early midwifery care, doulas' practice is often political, intended to raise consciousness and transform birthing people's gendered expectations of themselves and of parenting, not simply to increase personal autonomy and individual choice—unlike contemporary discourses of informed consent, informed choice, and patient empowerment.

Defensive Consent: Contracts and Rights

These more limited versions of consent are increasingly present in birth spaces as the history of midwifery activism fades and social movements like #MeToo draw popular attention to consent. In February 2019, for example, I received the “Quick guide to informed consent and refusal during hospital birth” in my email. It informs us that

the most important right you have in your healthcare is that of informed consent and refusal. It is based on the concept that you have autonomy over your body and in your healthcare—including when you are pregnant. You own your body!

Informed consent means you fully understand and freely choose what happens to you in your healthcare, based on thorough discussion of the risks, benefits, and options. Refusal means you have the right to say “No” at any time.

This guide was produced by BirthMonopoly.com, an organization that, since beginning this project in 2012, I witnessed grow from a single person deeply upset about her hospital birth experience to a website, podcast, and activist movement. The name refers to the monopoly doctors have over decisions in the birthing room. This version of consent is predicated on (legal) defense, as is much of the discourse on rape and nonconsensual sex:

Refusal of medical treatment is a basic right that has been strongly upheld by U.S. courts. The right to say “no” (refusal) is what gives your “yes” (consent) its power. National policy for obstetricians says that just like other patients, pregnant people have “the right to refuse treatment, even treatment required to maintain life.”¹⁴ You may change your mind and revoke consent at any time. No one has the right to touch you without your permission. You own your body. (emphasis in the original)

Power dynamics are highlighted here, and the relationship is imagined via rights, litigation, and ownership. A pregnant person's right to refuse even highly invasive procedures like caesarian surgery is not obvious, given discourse about fetal rights and the cultural discounting of mothers' subjectivity. Susan Bordo, in her aptly titled 2004 chapter, “Are Mothers Persons?,” shows how bodily autonomy and individual subjectivity (of the sort on which contract law is predicated) are not uniformly extended to pregnant people in legal and medical contexts.¹⁵

The contract metaphor, which is fundamental to liberal societies and underpins most ideas about consent, has been robustly critiqued by feminist and Marxist scholarship for presuming two independent individuals freely entering into a mutual agreement of exchange, which disregards the unequal conditions from which the two parties may arrive at the agreement. It is hard to say that a worker freely enters an employment contract when he or she has no other option to obtain food and shelter or that a wife freely enters a marriage contract in a context of women's social dependency and exclusive, hierarchical gender roles.¹⁶ The exchange metaphor does not create symmetry; in fact, it creates asymmetry by rendering power differentials invisible and irrelevant.

Contract logic presumes individuals as self-contained, autonomous units. Childbearing, where one body becomes two, is only the most literal example of the limits of such autonomy. In any caregiving situation, from raising children to tending the elderly or sick, relations of dependency condition the degree to which any person is an autonomous individual. The reproductive labor of caregiving is culturally feminized and racialized, propping up the presumed masculinity and whiteness of the generic “individuals” out of whom society is built. Carole Pateman argues that this feminization can only be seen as cultural to a certain extent, pointing to the real and persistent differences between sexed bodies.¹⁷ She asserts that a contract framework neglects not just power differences but material-biological ones, writing them out of the equation. Catherine MacKinnon has rather notoriously claimed that no male-female sex within a patriarchal society can be consensual, as there can be no consent in an unequal relation, and within such a society all those marked by their bodies' difference are less than full persons.¹⁸

Yet etymologically, consent means “with feeling” or “feeling together,” derived from the French sentir around 1300.¹⁹ Feeling together connotes agreement, approval, and accordance. This echoes the “meeting of the minds” in modern contract law; although this conceptual lineage may prioritize rational instead of embodied alignment, such synchrony contains multiple possibilities. Feeling, whether of emotion or bodily sensation, suggests a kind of attunement, sensitivity, and anticipation, something coproduced, as opposed to the patriarchal conceit of two self-contained individuals stating their positions as if in a vacuum. The complexity of the doula's work showcases these possibilities.

Doulas serve as a bridge between the political act of care and the legal practice of consent. In many ways they “translate” between these, helping clients discover their capabilities and desires and then acting as clients' “voice,” advocating for their interests, and mediating consent. The fact that these “nonmedical” aspects depend so heavily on empathy and intersubjective understanding is part of why many reproductive justice activists emphasize the importance of birthing people having doulas who share their demographic/socioeconomic/cultural contexts. Indeed, my own early experiences of being a doula for communities I wasn't prepared to serve speak to this.

In the birthing spaces in which I took part, then, there were at least two “consent relationships” taking place: that between doula and client, which is supposed to entail trust and synchrony, and that between doctor and patient, often imagined as requiring a defensive stance. Introducing a third party, the doula, into the relationship between patient and doctor facilitates a defense of rights, but, more interestingly, the way doulas facilitate this demonstrates a more qualitatively rich way of practicing consent in the first place: that is, as care. I call this “attuned consent,” which has three aspects that distinguish it from a rights/violation model of consent: (1) it accounts for complexity and ambiguity; (2) it foregrounds embodied knowledge, including receptivity; and (3) it is noncoercive without presuming “equality.” Unlike early midwifery care, attuned consent has to take place amid the fraught power dynamics of the hospital. Doulas do complex emotional labor to negotiate the perspectives, needs, and constraints of the various actors present in birthing spaces, and their own judgment, sensitivity, and ability to merge their embodiment with that of their client plays a large role in their effectiveness at attuned consent. Doulas' labor calls the paradigm of consent into question, even as it draws from it to accomplish its work.

Attuned Consent

In the hospital, Brynna and I slept. And woke. The fentanyl wore off, and the waves of contractions grew into nauseating tsunamis. Brynna vomited, violently but without much volume, as the time had long since passed when she was interested in the cornucopia of snacks we brought. I held back her hair, gave her water to rinse out her mouth. The midwife—when had she come in?—was asking Brynna to get back in the bed to have her dilation checked. Brynna didn't want to move, didn't want to stand or stay doubled over or lie down; she just moaned and swore weakly. She just wanted it to end. I wrapped my arm around her back, holding her up under her armpit to guide her to the bed. The midwife, a new one because the shift changed, put on a latex glove and lube. Sliding her fingers up to the cervix, she cheerfully announced that Brynna was at nine and a half centimeters! Almost there!

That was indeed good news, and becoming fully open, fully dilated, didn't take much longer. But pushing is a different beast from opening. We were blessed by an eye in the storm between the two phases, in which Brynna fell into a sudden and deep, if brief, sleep. After she woke, the nurse coached her in pushing—when the contraction blinked its green zigzag on the monitor, the blinking number that quantified its strength rapidly rising, the nurse said to take a deep breath and bear down, one, two, three, four, hold it all the way to ten, until your face turns purple. Give it everything you've got! Brynna gripped my clammy hand, and I gripped hers back. She looked into my eyes, rose no longer adequate, needing to focus somewhere steady enough to hold things together. Brynna pushed for all ten counts for a good hour—the towel was off the clock now that delivery was imminent. And yet the baby didn't seem to be descending. The doctor, for now there was a doctor too—when had he come in?—noted aloud both that the baby's heart rate was dipping during these intense pushes and that Brynna's pelvic muscles were too tense, were holding things up. Being told that you might be hurting your baby and that you should really just relax wouldn't be commensurate under the best of circumstances. In this case, they caused a panic.

Brynna's eyes swiveled toward me. “Am I hurting her? I don't want to hurt my baby!” she pleaded. The doctor thinks an epidural will cause relaxation, get Brynna out of her own way. I have never heard of this epidural relaxation idea, and I know it is unconventional to allow epidurals after seven or eight centimeters dilation, much less during pushing. Plus, of course, the needle. But really, I can see that Brynna doesn't care at this point. She is frantic about not doing harm with her body's pulsating strength. And the doctor, so confident, is stating his opinion as fact. He is not asking permission. Instead of pushing, Brynna must now breathe through the contraction with short little puffs, no more bearing down or purple face, waiting for the anesthesiologist. When he arrives, he curls her forward to expose her spine, the most uncomfortable position of all. The epidural goes in.

Still, the baby doesn't descend. There is no telling whether time is interminable or rushed. Somehow it's both. The sense of emergency siphons Brynna's strength and concentration away from pushing. They say something about the vacuum, a little assistance. Again, they don't ask permission as they push it inside her vagina. I ask them, Why the vacuum? But I don't remember what they say, because I turn my attention back to Brynna—she needs something to anchor to, to keep from falling to pieces.

The vacuum's suction ring grips the baby's head, halfway down the birth canal. The doctor tugs, and suddenly the ring slips off, sending the pulling doctor hurtling backward a few steps. It feels a bit surreal. He attaches the vacuum again and tugs on it again, and a purple, waxy baby slides out in a rush of greenish meconium. The purple is normal; the green indicates fetal distress. Brynna looks at me with laser focus; I am her link to her baby, being handled way down there, an ocean of numbness away. Our hands are still gripping each other. “She's perfect,” I tell her. “Your baby is perfect, you did it.” I hold her eyes. Mine tear up. Once the baby is toweled off a minute or so later, she is placed on Brynna's chest. Brynna's eyes have a new focus.

As we can see in this fieldwork anecdote, factors contributing to the difficulty of giving consent include exhaustion, fear of harm in an emergency (especially to one's baby), clouded judgment when undergoing intense sensations, and doctors' cultural authority and sometimes brusque demeanor. Factors may also include opinionated or emotionally trying family members and lack of information about patient rights and the benefits and drawbacks of various medical procedures. A doula is also influenced by these factors, though she generally has more distance from them than the birthing person does.

The anecdote I've told here was one of my earlier doula experiences, and I was conflicted afterward about whether I should have intervened about the epidural. From what I knew about birthing physiology and medical efficacy, it didn't make any sense, but I knew relatively little. Brynna at this point was even less qualified to determine whether she “consented” to an epidural, because she wanted to consent to anything she thought would help her baby, and assessing the medical necessity of a procedure was wholly outside her purview at that moment. I know that I provided an essential grounding function for Brynna, and I made connecting with her in the immediate present my priority, but being a consent worker is a complex endeavor with many shifting parts!

Complexity and Ambiguity

An attuned approach presumes that situations are complex and desires are ambiguous. It acknowledges that consent is not only ongoing and revocable but produced over time and in relationships with other people. Usually, a doula meets with a client a few times before labor to get a sense of what the pregnant person wants, cares about, and is afraid of. Sometimes a client has clear yes/no boundaries about what is absolutely necessary or must be avoided, but more often, she is collecting information, self-examining, and processing thoughts during these meetings and leading up to labor and often during labor itself. If a partner is present, that person's thoughts, feelings, and desires are part of this fluctuating mix as well. Often part of prenatal meetings is making a “birth plan” outlining what procedures the birthing person prefers happen or not and when. I increasingly found people referring to these as “birth wishes” instead to acknowledge unpredictability. Doulas bring their own experience and biases, though we are usually trained to minimize them. Sometimes people wondered how I could be a good doula when I hadn't given birth myself, and although it's not the only reason, I would usually tell them that I brought fewer weighty feelings and expectations to the situation that way. I could focus better on the birthing person's unique situation, which is what we are supposed to do.

The birthing person is complex enough herself; desires that may have seemed important during a prenatal meeting seem less so in the throes of labor, and there is often a reckoning that happens after the birth. It grapples with the questions, Why did things go the way they did, and how should I feel about it? The doula is expected to navigate between these past, present, and future versions of her consenting client. Do the person's words during labor represent her “real” desires, or is it “just the pain” talking? Some of the most glowing feedback I've encountered from postpartum people about their doulas is that the doula “didn't let me give in” or “reminded me of what was important to me.” On the face of it, the client/patient/birthing person simply says yes or no to the procedure; her consent is given or withheld in that moment, and that is that. But figuring out what is wanted is never so simple, especially for those marked by difference (including women generally) and more so when it is on someone else's behalf.

Ideas about how birth should unfold are heavily mediated by popular culture and a paternalistic medical system, much as ideas about sex are influenced by pornography. Both birth and sex are generally considered private and relatively taboo to speak about—the vast majority of people I worked with had never seen a human give birth and rarely even an animal—so achieving a clear sense of what one wants is challenging when ideas about what is possible and desirable are so shaped by heteropatriarchal media cultures. Attuned consent cannot presume that desires are constant, transparent, or even accessible. It has to acknowledge that they are intersubjectively produced and interpreted and that they happen within context: people make self-subordinating choices all the time that may attempt to mitigate damage or be strategic, given the power dynamics at work. Intersubjective does not mean simply interpersonal, transacted between two parties who both have stakes in the situation, but interdependent, as a person's experience and therefore their desire is influenced by multiple human and nonhuman agents present in the situation.

Embodiment

Second, attuned consent attends to the whole body, not just verbal expression. A doula's ability to be supportive depends largely on her ability to “read body language.” Reading body language requires intuition, which I have described elsewhere as a learned form of embodied knowing.²⁰ To intuit someone else via their body requires paying attention via one's own body, “active listening” without words. This is intense, skilled work! Similar bodily attunement is necessary in a number of situations where verbalization comes up short, such as consent with children or cognitively disabled people or in certain sexual subcultures. This is not to say that doulas never use words to ask for consent—on the contrary, that is common and good practice but inadequate for producing satisfying rapport. Part of being bodily attuned is knowing when and how to use words. Although it is important to recognize this feminized, often devalued communication as skilled, embodied attunement is also inextricably part of everyday life and something at which we might expect most people to be competent, if not expert.²¹

A popular iteration of consent describes it as performative: something one does versus something one feels or decides. Like “enthusiastic consent,” this well-intentioned modification is helpful though inadequate; it draws attention to the body, yet it implies that the body can transparently perform the will. Janet Halley distinguishes between “subjective consent” and “performative consent.” The former is “the internal state of mind of agreeing to something” whether because one positively and unambiguously wants it or because one perceives it as better than the realistic alternatives, while the latter is “the semiotic communication of agreement to something.”²² In my view, subjective consent is often complicated by ambiguity, as per my first point, and performative consent is complicated by considering the communication's reception, as well as its enactment. Listening—actively receiving—is a skill in and of itself. Like intuition, this receptive skill is feminized; a noncoercive culture would require people to learn to both speak up and to listen, regardless of gender.

Birth is a bodily experience for both the doula and the birthing person, and shared, intense bodily experience can create intimacy. I often cried at the climax of a birth, an urge that was somatic as much as sentimental, an involuntary release often accompanied by nausea or lightheadedness. In an unmedicated or lightly medicated birth, the birthing person often experiences a tipping point at which embodied intensity takes on a new level, which I heard described as a “point of no return,” where “the only way out is through,” and words are not really accessible anymore. The birthing room is a semiotically dense space where bodily attunement enables nonlinguistic understanding.²³ Ideally, understanding and intimacy create a situation of interpersonal trust. Such trust emphasizes dependency instead of autonomy, in contrast with a paradigm of rights and transaction that presumes self-interest is primary. Feeling safe and surrounded by trustworthy people facilitates giving up control, and a prominent discourse of surrender and “trusting one's body” posits relinquishing certain kinds of control as key to accomplishing birth. Consent that is centered around embodiment enables trust.

Noncoercion

Coercion refers to situations that are hard to refuse, over and above whether a refusal is respected or not. Relevant information extends beyond the immediate context: the person may have agreed to it, but did she agree to the conditions in which her decision was made, including any negative consequences for refusing? In birth situations, negative consequences can include hostility, bullying, neglect, or differential treatment (and, in extreme cases, force). Emotional messages activating shame or fear can be considered coercive, for example, invoking discourses of “risk” to persuade a person. Hospital situations often make medical procedures hard to refuse, including simply through the momentum of protocol. This is not necessarily within the control of people like doctors, who are complexly entwined with their institutional context. Doulas make refusal easier by offering reminders, asking questions, and making requests on behalf of their client. A doula is supposed to mitigate these power differentials through her tact, knowledge, and intuition.

Negotiating power dynamics requires a particular kind of emotional labor, as do navigating ambiguous desires and reading body language. Activist pamphlets can assert patients' rights, yet the power dynamics in the hospital room necessitate tradeoffs—a doula needs to be able to assert her client's wishes or amplify her voice without angering the hospital staff or interfering with time-sensitive emergency procedures. Even though it is within one's rights to refuse treatment required to maintain life, in the vast majority of situations birthing people want to prioritize their own and their baby's health and survival. The trick is that it's hard to tell what is really an emergency. From discussing birth room decision-making with midwives and doctors, I know that it is not always straightforward to them either. “Emergencies,” like judgments of risk, make things very hard to refuse, and negotiating what counts as an emergency is necessarily tiptoeing around coercion.

The political theorists referenced above claim that whenever there is a power imbalance accompanying embodied and social differences, there is necessarily coercion. While I am not in disagreement, it is important to not collapse equality and noncoercion. Equality is elusive not least because of the myriad intersectional vectors on which people can be compared. Perhaps a better goal toward noncoercion would encourage people to cultivate the ability to pay attention and make space for someone else's interests without feeling threatened by them, which is what doulas are supposed to do. As midwives do with regard to “informed choice,” doulas convey clinical knowledge to women and their partners in such a way that they can understand it while also “confirming and supporting women's own knowledge or gut feelings about their bodies and previous pregnancies in determining what is right for them. … [They] do not want women making decisions based on fear of childbirth pain, peer pressure, or popular conventions, but they do want to ensure that women feel safe and supported in their particular needs.”²⁴ This doesn't require or produce equality between the parties but redirects attention toward the birthing person and introduces a paradigm where different parties' interests are not opposed.

Discussion: Sexual Care, Political Refusal

This paradigm of “attuned consent” in birth resonates with two other contemporary cultural studies critiques of consent: Fischel's discussion of the limits of sexual consent, building off the #MeToo movement's insistence on it, and Simpson's analysis of Indigenous refusal to either consent or resist, sidestepping the narrow options offered by fundamentally hostile settler-colonial citizenship.²⁵

Sex and #MeToo

Birth is an intimate and highly gendered process that is related to sexual experience in multifaceted ways. Scholars of reproductive justice have long made clear that sex and birth are entangled in reproductive abuse, including within medical systems, while the recent #MeToo movement and the accompanying surge of attention to consent has spurred a popular consideration of birth in the language of sexual politics.²⁶ Terms like “birthrape” makes these parallels explicit.²⁷ Birthrape describes being/feeling genitally violated by medical personnel during birth, though some contest the term for diminishing the specific utility of “rape” as a concept and exacerbating the experience of birth trauma.

In any case, what counts as a sexual(ized) situation and what counts as a medical(ized) one are not only political questions but also cultural ones.²⁸ That is, comparing violations in birth with violations in sex not only draws attention to the power dynamics of the situation but encourages us to see how ideas about autonomy, trustworthiness, care, and reciprocity condition what counts as a “good” medical or sexual situation. The history of gynecology is full of examples of the cultural work required to create conditions where genital touching, looking, and inserting could possibly be vacated of sexuality.²⁹ Pulling discourses from the realm of sex into the realm of birth has been a key rhetorical strategy of activists pushing against birth's medicalized management, who often contest its cultural classification as a medical event in the first place by arguing that it is a normal physiological process. Drawing attention to parallels with sexual consent is a way to insist that birth exceeds a merely medical event and therefore requires different kinds of sensitivity and involves different power dynamics from pathological or emergency situations.

While overtly abusive and violent situations continue to exist in both sex and birth and should be denounced and prevented, #MeToo has raised attention to more subtle manifestations of coercion. Popular media documents the slough of campus programs, community initiatives, and household deliberations over how to educate the younger generations of any gender about communication, respect, and consent. There have been prominent media discussions attempting to account for “bad sex.”³⁰ There is a vast “gray zone” between rape and mutuality that is opening up for cultural examination.

Fischel problematizes the ubiquity of “consent” as a framework for navigating this gray zone. He offers a provocation to imagine more creative and ethically capacious ways of approaching sexual interactions, arguing that consent is important as a legal concept but insufficient (and in ways downright damaging) as a political one.³¹ By looking at kink and other nonnormative types of sexual practice, he details the limits of attempting to improve upon consent by calling for it to be enthusiastic, ongoing, affirmative, and/or performative, critiquing an obsession with getting “good consent” instead of having “good sex.” “Enthusiasm” may not be sexy or present in great sex that was mutually enjoyed, and coercive power differentials can persist regardless of enthusiasm. Contrary to numerous progressive slogans, Fischel claims that consent is not in itself sexy. While important, it is inadequate to address the dissatisfactions and malcontent that suffuse contemporary sexual culture. Conceptual tools designed to deal with rape are meager in the face of qualitative nuance; feeling violated is a major problem for which consent is an inadequate response.

Likewise, consent is important but inadequate in birth. Sex and birth are both highly embodied experiences. Not attending to the ways bodies express themselves is bound to be inadequate for producing satisfying, respectful sex or birth. Defensive consent discourse has an important function in asserting that the birthing person is in charge of what happens to her body, yet innumerable qualitative factors produce the difference between a satisfying birth experience and a traumatic one. The qualitative complexity that doulas navigate could help reframe contemporary consent discourse. Considering doula-supported birth offers a way to conceptually disentangle consent as a term of legal defense from consent as a (flawed) platform for relating.

This is obviously not to propose a third party moderating consent in sex, which is at least improbable, but to make a case for care alongside consent in the conceptual toolbox. How would sexual consent that draws from care translate (or not) into popular and media situations? What would it look like to make the midwifery transition in the other direction? Instead of borrowing consent as a more palatable and transferable frame, could we introduce the complexities of care as necessary considerations? How should we conceive of sexual care as attunement, which does not necessarily entail and may be entirely separate from romantic love but which takes complexity, embodied attention, and noncoercion as a starting point?

Refusal

These issues raise the question of what possibility there is for meaningful consent within a fundamentally uncaring frame. Care is not a term used by Simpson in analyzing Indigenous political possibilities, but her germinal theory of refusal is relevant here. She does not mean refusal to consent, which is simply resistance, but refusal to play a rigged and hostile game. Both consent and resistance are “easy answers,” she says, while refusal is profoundly not easy, because it opens the door to the unthinkable, to options that are not currently on the table. In describing her ethnographic and personal engagements with an Indigenous North American community, she draws her concept of refusal from “the very deliberate, willful, intentional actions that people were making in the face of the expectation that they consent to their own elimination as a people, that they consent to having their land taken, their lives controlled, and their stories told for them.”³² Refusal to play various games of citizenship (voting, paying taxes) calls out the deeply unequal scene of articulation of the settler-colonial present.

Within such an uneven, predetermined, and violent field for interpretation, “resistance” becomes a repetitive stance that overinscribes the state with the power to determine what matters, treating domination as an all-encompassing frame for action. For Simpson, refusal is a stance taken by her interlocutors, a writing strategy, and an analytic that stands outside this repetitive stance. It is a political posture of acute awareness of the conditions of its production, pointing squarely at the “presumptive falsity of contractual thinking, … [which is] the notion of two parties knowingly abstracting themselves out of their own context to contract into an agreement.”³³ The political here is not merely about moves in a game of power, including moves that contest the original distribution of power, but also about “a push on what should be.”³⁴ Erica Weiss describes refusal as a decision to invest hopes and energies else-where, “an affirmative investment in another possibility … a kind of ‘playing dead’ to avoid the traps of citizenship.”³⁵ The opening toward other modes of politics begins with recognizing that established channels of dissent are only available to those more aligned with the current hegemonic structures and that such channels themselves bolster the fundamental conditions in which possibilities are registered.

Simpson sheds light on how saying no within hierarchical contexts is rarely, if ever, neutral. Settler colonialism is not eventful but enduring, with its own structure and logic and refusals. These refusals to acknowledge, much less nurture, other possibilities remove the significance of consent. In philosopher John Locke's classic theories of consent as the root of legitimate government, both explicit and tacit consent to be governed require that opting out actually be a viable option.³⁶ Instead, saying no turns into resistance, being “uncooperative” and “unreasonable.” This certainly happens in hospitals. Stereotypes about difficult patients are particularly strong in birthing contexts, particularly for birthing people subject to classist and racist judgments. Even for less marginalized people, the decades following the women's health and natural birth movements saw much apprehension and hostility on both “sides” as birthing people who wanted slow care and minimal intervention confronted hospital staff inclined toward efficient routines and heroic medicine.

Midwifery and homebirth as social movements were (and are) attempts to stand outside existing options.³⁷ They are akin to what Simpson describes, albeit on a less existential scale. Among some whom I spoke with in the white midwifery community, turning care into consent through professionalization was a deal with the devil, taking such refusal and transforming it into mere resistance. To varying extents, doulas take up this slack, making space for the excess aspiration that is not recognized by institutional possibilities. Particularly for doulas and clients of color or for marginalized genders and sexualities, insisting that space be made in which the choices on offer can be refused entirely is both particularly challenging and particularly important. The work of the doula is to absorb these contradictions, mediating between different registers of possibility and risk, making care matter in a space that is not built to encourage it.

Conclusion

Attuned consent shows how the doula facilitates the negotiation and enactment of autonomy. Her work enabling consent involves mediating between parties, shifting between registers, reading between the lines, interpreting, translating, and connecting. This way of thinking/doing consent foregrounds the ways persons are not static or self-derived and demonstrates that desires are not produced in a vacuum and available to perform at will. Attuned consent reveals autonomous individuals as a fallacy, although it does take individuals and autonomy seriously. By looking closely at how “consent” works when mediated by a doula, we can see many of the shortcomings of a rights-based consent framework, as well as think specifically about attunement as a means for satisfying, respectful, and nurturing relations, be they in birth, sex, medicine, or citizenship. A recent popular piece succinctly sums this up: “Consent provides a way to protest treating other people as objects. But when it comes to treating other people as people, we have a ways to go.”³⁸

Ideally, doulas transform the birthing person's experience of care into an institutionally relevant language and in turn transform hierarchical institutional conditions into a rich experience of being cared for. Doulas are a bridge between worlds of political possibility, albeit one frequently constrained by the exigencies of existing power dynamics. Treating social interactions like contractual market exchanges obscures the cultural, political, and material contexts that produce the meanings and imbalances that the recent surge in consent discourse attempts to address, yet it is the very inadequacy of this liberal economic model that creates the traumas that need correcting. This is the irony at the heart of consent. The fact that doulas often provide market-based services exacerbates this irony, yet it also illustrates the paradoxical difficulties of refusal, which has to happen from within existing conditions. As such, the hybrid phenomenon of the doula as (non)medical provider provides a timely window onto the American political moment.