Accompanying the Path of Maternity: The Life History of a Colombian Doula

Abstract

Doulas have fundamentally improved the health-care experience of pregnant women internationally. Women who recognize the importance of not being alone during pregnancy have embraced this role for centuries. However, less is known about doulas practicing in countries experiencing health inequities like Colombia. Miller's methodology and Atkinson's interview domain was used to answer the question “What life experiences led a Colombian woman to become a doula?” A central theme emerged, “A calling from within: Growing up to accompany the transition from woman to mother.” The path to becoming a doula evolved from life experiences involving health inequities, and a sense of femininity, maternity, and the women's role in rural Colombia.

The word “doula,” derived from ancient Greek, means “woman's servant” (DONA International, 2019). Doulaism, initially practiced by women instinctively and with gender empathy, provides support, well-being, and companionship to women during gestation, birth, and puerperium. Doulaism was recognized in 1970 as a role to address the needs of pregnant women within health-care systems (Meadow, 2015). Doulas provide companionship during the labor and birth experience from a nonmedical perspective. The doula is a “trained health worker who provides continuous informational, physical, and emotional support for patients during pregnancy, labor, and immediately postpartum” (DONA International, 2019). A doula understands gestation as a process of transformation, which must be addressed in a culturally-sensitive way thereby elevating the woman, and providing births with honor. There are antenatal doulas, birth doulas, postpartum doulas, and doulas for souls (Doula Caribe Internacional, 2019).

Women are led to become doulas via their life experiences (Eftekhary et al., 2010; Hardeman & Kozhimannil, 2016). A life history approach (Atkinson, 1998; Miller, 2011) was used to answer the following question: What life experiences led a Colombian woman to become a doula? This paper presents the life history of a Colombian doula. This life history personifies the voices of other Colombian doulas and provides a perspective to enhance women's health in regions experiencing health inequities.

BACKGROUND

Colombia faces a maternal health-care crisis due to inequities and barriers primarily affecting minorities and low-income women resulting in increasing maternal and infant morbidity and mortality (Sandoval-Vargas & Eslava-Schmalbach, 2013). Countries including Brazil, Canada, Chile, England, United States, and Sweden explored Doulaism as a way to address these issues via improvement in health care for pregnant women. Neel et al. (2019) state that doulas promote beneficial outcomes during pregnancy by decreasing cesarean surgery rates and increasing breastfeeding hereby enhancing labor, birth, and birth experiences. Importantly, doulas are helpful for adolescents, marginalized populations, and ethnic minority groups (Pugin et al., 2008).

Doulas provide nonmedical interventions and constant support to pregnant women by facilitating access to health services and enhancing its quality (Kozhimannil et al., 2016). The presence of doulas reduces racial disparities by providing both culturally-congruent care and promotion of diversity in pregnancy, and physical, emotional, social, and spiritual support (Gilliland, 2011).

The introduction of trained doulas in birth rooms improves skin-to-skin contact and has a positive impact on maternal and perinatal outcomes (Lanning et al., 2019). The presence of doulas is critical in settings where women may not have companionship such as abortion (Chor et al., 2012). Doulas provide emotional support during miscarriages and contribute to engagement of women in acquisition of the maternal role, thereby positively impacting health-care interventions and outcomes for women and infants (Barbera & Inciarte, 2012; Campbell-Voytal et al., 2011; Hans et al., 2018; Meadow, 2015; Valdés & Morlans, 2005).

Doulas are acknowledged for their practice, however, the learning process of this practice is not well understood. The learning of Doulaism is primarily a self-learning process taken on by women who decide to accompany other women through the process of becoming mothers. Meetings between experienced and novice doulas to share knowledge and experiences are key to the learning of Doulaism. An understanding of doulas' learning, knowledge, practice, relationships with health-care professionals, and perspectives about maternity is limited. This study proposes to describe the experience of learning and practice for a Colombian doula using a life history approach. The question is: “What life experiences led a Colombian woman to become a doula?” This life history personifies the voices of other Colombian doulas and provides a perspective to enhance women's health in Colombia and internationally in regions experiencing health inequities.

METHODS

This life history used Miller methodology (2011) and Atkinson's interview domain (1998). Information was processed via double hermeneutics through the subjective interpretation of the doula's life by herself and the researcher (Miller, 2011). Interpretative analysis was constructed by identifying referential frameworks in speech, patterns of information, dynamics of language regarding word meanings and their use, generation of codes through analysis, interaction between the doula and researcher, and construction of life history through a comprehensive process of collection/interpretation, extraction/codification, and action/interaction (Miller, 2011). This life history follows recommendations for thematic synthesis and creation of categories by Sandelowski and Barroso (2007), thereby providing a comprehensive product that preserves findings of existent publications. Categories and subsequent themes emerged via inductive analysis and association of propositions.

Purposeful sampling allowed identification of a doula representative of a typical case of Doulaism in Colombia (Palinkas et al., 2015). The interviewee was a Colombian doula practicing in Bogotá. The researcher who is bilingual and a native of Colombia had previous acquaintance with the Colombian Doula via clinical practice as a midwife in Bogotá (Creswell & Poth, 2018).

The Institutional Review Board approved this study. The first author carried out a 9-hour videoconference with the doula following her own personal timeline, with pauses every hour and a half to 2 hours. The interview, conducted after informed consent, included an open-ended question and used nondirected interview techniques as recommended by Atkinson (1998) (Table 1). The audio-taped interview was transcribed verbatim. Line-by-line analysis accomplished first and second cycle coding. Field notes enriched the interview transcription and categorical and thematic analysis conducted in Spanish by the researcher (Heale & Twycross, 2018; Sandelowski & Barroso, 2007). Translation of the interview excerpts, categories, and the general theme were made in two forward and one back translations by three bilingual translators fluent in English and Spanish. This life history was evaluated using criteria of credibility, dependability, and transferability as described by Guba and Lincoln (1981) including implementation of double hermeneutics and verification of information and thematic analysis of the transcript by the doula and authors.

TABLE 1. Atkinson's Dimensions for Data Collection and Analysis in Life Story Approach.

The eight dimensions that comprise the interviews guided the encounter between the subject and the researcher. Birth and the family of origin Cultural and traditional scenario Social factors Education Love and work Main events and historical periods Inner life and spirituality Imaginable

LIFE HISTORY

L was born in Valle del Cauca, a rural region in Colombia. She is 39 years old, and has been practicing Doulaism for 13 years. L considers herself an Afro descendant. L began sharing her life by recalling childhood memories using a linear narrative. A central theme emerged: A calling from within: Growing up to accompany the transition from woman to mother, that is constructed by five predominant categories: (a) foundations, background and inspiration, (b) sources of doula knowledge, (c) doula's practices, (d) getting rid of her fate by means of her will, and (e) the doula in action. The English translations of excerpts are included for substantiation of the theme and categories. The original Spanish excerpts are included in the Appendix.

FOUNDATIONS, BACKGROUND, AND INSPIRATION

This category emerges from the influences on her life. L grew up in a rural region of El Valle del Cauca (The Cauca's valley) surrounded by women, especially her grandmother. L, like thousands of Colombian girls, was forcibly displaced by mafias involved in armed conflict. Art and the social support from neighbors and her extensive family moved the deepest fibers of her being.

Surrounded by women. “I'm a granddaughter of a granny who gave birth thirteen women (she laughs), … there are so many women, and my memories of life is being there … surrounded by many women …”

Through her narrative, L speaks constantly about being raised by women, and how their influence was critical for the decision she made to become a doula. L's perspectives of the maternal role and a woman's role in society were framed through the eyes of a little girl.

Big family. “Like all the time we need to reunite and celebrate and that, hmmm… the tradition, for example, of going by the river every weekend … uh … cooking by the river, getting together and with the neighbors … at night … that tradition of coming out in the afternoon to receive the fresco (cold breeze in warm days) … they (grandparents) outside seated on the chairs or on the sidewalk … and all the neighbors getting out to talk and speak … that was… is so cultural of us…”

Although L was an only child, she was surrounded by a big family. She describes that in addition to 13 aunts and their husbands, grandparents, and cousins, the culture of her region brought together all the neighbors and their families as a single big family.

Role model. “My grandmother is for me… she is my hero … for me … she is a woman … that… for us or for me … she is my role model … she is the role model of life … she is wonderful … I hear her history every time I can from my aunties, and I say “wow!” That is … if I were in her situation … I've said that I wouldn't have been able to do all what she did.”

The presence of her grandmother was a fundamental inspiration; she is always present. L is constantly missing her, the emotions in her voice were so vivid, such that variations of her tone transmitted the excitement, pride, and sadness L experienced.

Influenced by art. “Umm… despite all the situations in my house … the joy was astonishing … you can't imagine … we are totally musical … so the music is in the morning … in the afternoon … at night … the food … the reunion … the family. Dance was what helped me to adapt myself to all those places … that was what influenced me the most.”

Art is a recurrent topic in her narrative describing both the influences of dance and music within her family and the childhood dream of becoming a dancer. Such a dream led her to further understand the labor and birth process as a dance performed through a synchronic motion.

Losing and loneliness. “So … that is another story … I'm… what maternity brings to me was a mad thing because it brought me great depression … I was depressed a lot during my pregnancy … I didn't eat … It was so hard … I was alone … my mother was in Armenia … then I realized … to have a family … one needs to have a network.”

After L's grandmother died, a constant feeling of loneliness was present and filled only by her children and being a doula. Her mother was absent during the hardest times in her life leading L to miss her grandmother profoundly. Facing maternity alone became one of the reasons L was moved to accompany other women during pregnancy.

Finding gaps and listening. “… a lot of pregnant women … they have tons of questions … they don't feel comfortable asking the gyn-obstetrician … prenatal course they attended … neither had those answers … about their fears … their doubts … their questions.”

L began to listen to pregnant women, and found that the health-care system did not meet their needs. She realized that her experiences during pregnancy were similar and began providing other women opportunity to share fears, questions, and expectations. L was again surrounded by women, just like when she was a child, but this time all of the women were pregnant.

SOURCE OF DOULA KNOWLEDGE

As L shared her life history, she realized that throughout it she acquired skills needed to perform Doulaism. Other events moved L to continue this practice, beginning with her own pregnancy.

Learning and being there. “… She (doula) … she got us ready … that helped me a lot … at last a person to talk with about all these things … I thought my connection with M (doula) was unbelievable … I could … talk and talk with her about all my fears and all my stuff.”

The constant presence of M during her pregnancies helped L to understand that her dream could be real in Colombia, and she was not alone. Her voice was not the only one, and having experienced such wonderful births, she was moved to replicate her experiences in the lives of other women.

Learning from other women. “But to be a mother … you need a network … because who else is going to teach you if is not your own mother … or your female cousins, or your aunties? … Especially here … where everything is so, so, so … chaotic … everybody is doing their business … and so … one needs … to have a network.”

When L was pregnant, she found herself alone, with no one to teach her how to be a mother. This situation made her aware that women still learn the nuances of maternity, mainly from other women. L understood that just like her, there must be other women feeling alone. So, she decided to “be there” for those women.

Responsibility taken by love. “That first birth for me (as a doula) was like the achievement … the dream of being able to say “I am accompanying a mother in a hospital', so … do you get me? That … for me … I believe … after so many years, what I was envisioning and had wanted …”

L describes the satisfaction of being a doula and highlights how important it was to make the practice accessible to all the women as Doulaism had become a service exclusively for women with social advantage. L always dreamed to be a Doula in a public institution or at least to accompany those women of middle and low incomes. Such events allowed her to identify the needs of those women who represent most of the births in Colombia.

Learning from experience. “I had a hard time with breastfeeding because of many situations … I found a lack of breastfeeding guidance … breastfeeding companionship by nurses … by pediatricians who had no idea, and my (birth trainer) … who was very good and had so much experience with births … lacked information on maternal breastfeeding … I got mastitis …”

L not only felt the consequences of loneliness and a lack of support, she also experienced a lack of health information. This is not because birth trainers do not teach about women's care rather because of the insufficiency of information.

Doula's Practices

L's life history focused on nonclinical interventions including emotional support and the authentic presence; being available to promptly address needs of pregnant women and their families, for instance:

Reliving fear. “The first birth I accompanied … was actually of a friend of mine … who I met and helped from Ibague and is pregnant, and said to me ‘L … I want you to accompany me because the baby's father is super nervous.’

Instinct. “I was the companion all the time … giving her massages … I didn't know anything about doula … nothing … I mean, it was very instinctive … massages … accompanying her breathing … making movements, it was instinctive rather than really knowing what I was doing.”

L's physical presence and her authentic interest in pregnant women and partners helped to calm anxiety and worry during pregnancy. Although L accompanied the pregnancy and labor of her friend, she was not allowed to stay during the actual birth. L did notice, however, that her presence helped her friend to stay calm and feel better.

Providing support. “Simply … I am a woman who supported other women and other families … a change agent … I consider that being a change agent is important.”

Accompany. “A doula is a woman that supports … accompanies a woman or a family throughout the pregnancy, birth, and postpartum process … and …when I talk about accompanying … I say that accompanying and supporting is like … the verbs that define our companionship.”

The principal characteristic of a doula is companionship. A doula becomes part of the pregnant family, being aware of needs that may arise and providing comprehensive emotional, spiritual, and physical support, which sometimes occur simply from being there.

Informing. “Then I started looking for information … let's say, for all those couples … when they arrived … they already had the information that I gave them, recommendations on physicians, recommendations on clinics, recommendations of everything.”

Sharing the knowledge. “We have doula certification with Doula Caribe … I said, ‘Ok, … we need Doulaism … in Colombia … we need more doulas’, and I created a certification … we ended up meeting so many women that were doulas in one way or another way … for so many years … but everyone as prenatal educators or birth accompanier, but not with the given name of doula.”

L describes how teaching and providing information is fundamental to obtain beneficial results of her practice. Moreover, the doula must be an expert about the health-care system and available resources. The doula has the duty to teach other women who decide to become companions for other women, by performing training, and obtaining certifications in Doulaism, especially in Colombia, where there are no official institutions for Doulaism.

Managing the pain and fear “‘Well, you're already at 8 (centimeters), we're heading out from home’ but he always told me … that he doesn't believe I was delivering and I was like ‘but, why?’ he said, ‘because I can't believe you are a woman … who doesn't feel pain’ And I ‘I do feel pain, what happens is that I breathe a lot and it doesn't mean it doesn't hurt” … that delivery hurt … but it was different, I was like accepting that pain.’”

Comfort and movement. “During the birth labor I am always giving to the mother the means for comforting, such as massages, acupressure, reminding her to breathe, suggesting her movements, positions, feeding her, hydrating her … pamper her all the time together with the father … In the crowning stage, I help her a lot regarding the expulsion, along with the doctors I work with … I utilize a lot the rebozo technique to make the expulsion more amenable and for the mother to know when she must push, for her to know well where she has to push when.”

L has extensive knowledge about massage, breathing, movement, and positioning that make her practice distinctive from other doulas. Her interventions, informed by understanding of yoga and dance, relieved pain and discomfort during the labor and birth process. L expressed that her own experiences during pregnancy affected those techniques she has refined over the years.

GETTING RID OF HER FATE BY MEANS OF HER WILL

When L was a child, she felt the impact of armed conflict and drug traffic in Colombia. The machismo culture and a landscape without opportunities were not barriers for L and her mother to get ahead in life.

Gender stigma. “My grandmother… well, the story of hers is, is a shocking story … is a woman who was a Farmer and she … in that time … one of the woman's visions was to get married, have a husband … give birth … so many children … and raising them.”

Being a mother. “My grandmother was like the center … then it was wonderful … I felt pretty good because it was about being together all the time … with all the situation that families have … obviously … but she was the cornerstone and everybody around was attentive to her … my aunties … took all the grandchildren for her to take care of them … she welcomed all of them … all … Come on … she was the happiest … with all the grandchildren, such an experience of being at home with her was the best.”

L tells with resignation and pride how her grandmother was a victim of violence and assumed the societal role to bear many children. The stigma of being a woman in rural Colombia shaped her early years at school. Nevertheless, this became a duality, because by observing her grandmother she noticed how the family and the society are constructed around a female figure.

Women empowered. “When one feels that one gave birth to a baby … to a living being … is like… what I said … before or after having a child one feels like one can make it against the world … it is such an empowering experience.”

The teachings her grandmother planted in her represent the strength in her will, facing the adversity, and feeling empowered through giving birth a baby. These characteristics were fundamental to start the endeavor of changing the paradigms on maternity in Colombia, promulgating her philosophy of life as a doula.

Facing adversity. “But my memories are from them … I was three years old yet trying to endure the situation … my aunties were already grown … my mom, everybody working … always trying to get over it.”

Finding the path. “… I want to study … but I don't want to be a physician, or a doctor, or a nurse, I want to be a doula … that doesn't exist in Colombia … the doula profession doesn't exist … to be a doula you must go to Spain …”

In the absence of an option to accomplish her dreams, L tells how she searched to learn how to become a doula. L found that study abroad was the only way to start a movement that changed the perception of giving birth in Colombia.

THE DOULA IN ACTION

Life as a doula has not been easy for L as decisions and bittersweet experiences created new challenges in a story that seems endless.

Gratitude to life. “You know … I never faced any difficulties because I feel that … that I was so happy in my childhood with the things that they (grandparents) gave me … because … despite no luxuries… that's it… it was having them … it was having a house … I was really happy in my childhood.”

Having a dream. “And in that moment … there was a TV channel … I don't know if you remember … that shows … births and I saw those deliveries in the water and so I said ‘I want to give birth this way…. … Nothing, no, no, what? … That doesn't exist in this country … that thing doesn't exist here.”

The life of L represents some of the experiences that Colombian families live daily; being displaced by violence, and moving through different cities looking for a better tomorrow. Such strength shown by the women in her family was the inspiration L needed to see another option that was unavailable in Colombia by that time. This inspiration woke up the fire inside her spirit to pursue her vision of the ideal birth process.

Being understood. “Because sometimes there are moments in which one feels there is someone who judges you and says… ‘What are you thinking?’ or… ‘Others say you are crazy because that thing is not going to happen here, and is not going to ever exist.’

Being the first. “When I introduced myself and said that I'm from Colombia …Where is Colombia? … Is it in America? … Well ok … that was like no one had any idea … there wasn't a reference about doulas … about nothing … then I felt so proud because I said …Well, I'm going to be the first certified one …”

Finally, after a long search, she found someone and was not alone. This support motivated her to go abroad to get formal training, becoming a referent for Doulaism in Latin-American.

Doula challenges. “I understood the context in which doulas in South America weren't so accepted within the environment … within healthcare … because they weren't accepted … understand that was almost a challenge to arrive in Colombia to look for a spot and begin to work.”

Building bridges. “I always have been extremely careful and respectful of the process … because always I have felt that… always believed that my job was not to arrive to fight the system, but rather enter so subtly … recognizing everyone's job.”

L's history evolves as she opens different venues for Doulaism in Colombia, but this was not enough. There is a long path to walk based on mutual respect and teamwork for all of those, who like L, work for the well-being of pregnant women.

Bad practices. “… Bad practices made Doulaism frowned upon, didn't it? Like we came here to fight against the system, but there were actually some bad practices.”

Healing wounds. “I was hospitalized for three weeks … I couldn't move … because … contractions … and … the fear of water breaking … and I was hospitalized until the 35th week … pretty good … well assisted … just waiting … waiting for the cervix to close and contractions to cease.”

Advancement of Doulaism in Colombia requires collaboration between doulas and the health-care system. Many doulas have followed L's path but with different ideas and perspectives grounded on their negative experiences. Their opposition to the health-care system closed instead of opening doors toward acceptance of Doulaism in health-care institutions.

All these categories can be encompassed in the main theme A calling from within: Growing up to accompany the transition from woman to mother. L decided to become a doula driven by her experience of maternity, and by the inspiration from her role models.

Finding out after so many years that my grandmother ended up being a partera just because in the countryside … having given birth so many children, makes her a woman that had experience … then they ended up calling her (a partera) … that was beautiful for me … I think that is important … I feel … there had been a seed … I feel it had to be in the DNA.

DISCUSSION AND PRACTICE IMPLICATIONS

L is a prototype, a Colombian woman led to Doulaism through the context of life experiences. Such a context was greatly shaped by female influences, ancient traditions, and art (Gentry et al., 2010). Consistent with Hardeman and Kozhimannil (2016) insofar as doulas found their call through their own maternity experiences, L received training as a doula initially by her own means, to provide pregnant women with the support she missed during her own pregnancy. She recognized the importance of this support and hence, the need to get a formal training to achieve official recognition of her role.

Kozhimannil et al. (2013) show that the incorporation of Doulaism into the formal health-care system may benefit the nurturing of pregnant women. Colombia and other countries with communities experiencing health disparities ought to make Doulaism widespread and accessible, aimed to improve pregnancy outcomes and other woman-related indicators in clinical settings. Importantly, the inclusion of doulas into the formal health system and childbirth education must be done gradually and with constant discussion with health-care providers to avoid those confrontations described by L as well as reported in other countries and settings with health disparities (Lucas & Wright, 2019; Neel et al., 2019). Considering that doulas provide interventions focused on companionship to promote the emotional well-being of pregnant women, childbirth educators can learn from them with the aim of seeking the humanization of a health-care system that historically has diminished and violated women's sexual and reproductive rights. As L stated, being there, emotionally and authentically present, is the doula's main goal. Generations of an empowering transcendent and authentic relationship between doulas and pregnant women promotes this emotional well-being.

A limitation of this study is the inclusion of one life history. However, the life experiences of the Colombian doula, L, exemplify struggles that pregnant women, particularly those experiencing health disparities, face when accessing maternity care in health-care systems. Community support of doulas is critical in transitioning this role to health-care systems internationally thereby promoting the progressive inclusion of doulas in maternal assistance (Ballen & Fulcher, 2006; Gilliland, 2011; Keeslar, 2013; McLeish & Redshaw, 2018).

CONCLUSION

This life history of a Colombian doula provides an understanding of her life and the events leading to Doulaism. Given the Colombian context, as a mostly rural country with significant indigenous influence and native cultural traditions, L's life history likely reflects the lives of other Colombian doulas. Likewise, the primary influences on her learning, practice, and the challenges experienced regarding inclusion of doulas in the Colombian health-care setting is realized. Further study including perspectives of Colombian doulas and verification of the effectiveness of the Doulaism in the Colombian context, as well as internationally in areas experiencing health inequities, is indicated.

Biographies

DANIEL F.M. SUÁREZ-BAQUERO received his BSN and MSN in Maternal/Perinatal Nursing Care from the Universidad Nacional de Colombia. He is currently completing a nursing PhD at the University of Texas at Austin. His research and practice concern maternal/perinatal health, risk reduction for urban/rural ethnic minority women, and analysis of nursing theory.

JANE DIMMITT CHAMPION is a professor at the University of Texas at Austin. Dr. Champion has conducted research, practiced, and published extensively since 1995 concerning Hispanic health internationally. Specific foci include women's health and primary care interventions for Hispanic populations both rural and urban internationally.

Appendix. Original Excerpts in Spanish

FOUNDATIONS, BACKGROUND, AND INSPIRATION

Surrounded by women. “Soy nieta de una abuela que parió trece mujeres (risas), entonces son demasiadas mujeres, y mi recuerdo como de vida es estar ahí, rodeada de muchas mujeres …” [I'm a granddaughter of a granny who gave birth thirteen women (she laughs), then there are so many women, and my memories of life is being there … surrounded by many women …].

Big family. “Como todo el tiempo tenemos que reunirnos y celebrar, y eso, mmm… la tradición, por ejemplo de ir al río todos los fines de semana, e…a… cocinar en el río, reunirnos y con los vecinos, en las noches, esa tradición de salir en la tarde a recibir el fresco, ellos afuera sentados en las sillas o en el andén y que salgan todos los vecinos a hablar y a conversar, eso fue… eso es súpercultural nuestro…” [Like all the time we need to reunite and celebrate and that, hmmm… the tradition, for example, of going by the river every weekend, uh … cooking by the river, getting together and with the neighbors, at night, that tradition of coming out in the afternoon to receive the fresco (cold breeze in warm days), they (grandparents) outside seated on the chairs or on the sidewalk, and all the neighbors getting out to talk and speak, that was… is so cultural of us…”].

Role model. “Mi abuela es para mí… es mi heroína, para mi ella es una mujer e… que… para nosotros o para mí, como tal, es mi ejemplo a seguir, es el ejemplo a seguir de vida (…) Entonces e… para mí…mí abuela es ese… es maravilloso, o sea, es mi ejemplo a seguir, porque es la heroína, es ves… escucho su historia cada vez que puedo de mis tías y digo “Wow!”. O sea, yo me pondría en su situación y diría yo hace rato no hubiera podido hacer todo lo que ella logró.” [My grandmother is for me… she is my hero, for me … she is a woman … that… for us or for me she is my role model … she is the role model of life … Thus… uh … for me… my is… she is wonderful, she is my role model because she is the hero, she is… look… I hear her history every time I can from my aunties, and I say “wow!” That is, if I were in her situation … I've said that I wouldn't have been able to do all what she did”].

Influenced by art. “Em… pues a pesar de todas las situaciones de mi casa, la alegría era impresionante, o sea, no te imaginas, somos totalmente musicales e… entonces la música está en la mañana, la tarde, la noche e… la comida, la reunión, la familia (…) la danza fue la que me ayudó como a adaptarme a todos esos lugares, a todos porque lo primero que hacía era buscar una escuela de danza y estar ahí, pero eso fue como lo más que me haya marcado así de resto.” [Umm… despite all the situations in my house, the joy was astonishing … you can't imagine … we are totally musical … so the music is in the morning, in the afternoon, at night … the food, the reunion, the family. Dance was what helped me to adapt myself to all those places … to all because the first thing … what I used to do was look for a dance school … and being there … but that was what influenced me the most].

Losing and loneliness. “Entonces, e… eso ya es otro historia, yo soy… lo que a mí me trajo la maternidad fue una locura, porque me trajo una depresión muy grande, yo me deprimí embarazada un montón, no comía. Fue muy difícil, estaba sola, mi mamá estaba en Armenia, esta ciudad es demasiado… Ahí yo me di cuenta que uno… para tener familia necesita tener una red.” [So … that is another story … I'm… what maternity brings to me was a mad thing because it brought me great depression … I was depressed a lot during my pregnancy … I didn't eat … It was so hard … I was alone … my mother was in Armenia … this city is too much … then I realized … to have a family … one needs to have a network].

Finding gaps and listening. “En mi escuela de yoga muchas mujeres embarazadas, muchas, y con todas empiezo a encontrar que son, que tienen demasiadas preguntas, que no se sienten muy cómodas hay veces haciéndoselas al ginecobstetra, que el curso que al prenatal que iban no tampoco, no tenía como esas respuestas y al final siempre mi clase de yoga aparte terminaba más en una reunión de todas las mamás hablando cada una de sus miedos, de sus dudas, de sus preguntas.” [In my yoga school … a lot of pregnant women … they have tons of questions … they don't feel comfortable asking the gyneco-obstetrician … prenatal course they attended … neither had those answers … at the end … my yoga class ended up turning into a meeting of all the mothers talking about their fears, their doubts, their questions].

Source of Doula Knowledge

Learning and being there. “Y ella nos hizo en el curso prenatal, nos preparó, a mí me ayudó un montón, o sea, yo ya poder tener una persona con la que hablar de todas estas cosas que pensaba, aunque mi conexión con M. fue increíble, o sea, es decir, yo podía ir a consulta y hablar y hablar con ella ac erca de todos mis miedos y mis cosas.” [… She … in the prenatal course … she got us ready … that helped me a lot … at last a person to talk with about all these things … I thought my connection with M was unbelievable … I could go to the appointment and talk and talk with her about all my fears and all my stuff.

Learning from other women. “Pero para ser madre necesitas una red, porque quien más te va a enseñar si no es tu misma mamá, o tus primas, o tus tías? y más aquí, en esta ciudad, donde todo es tan, tan, tan… porque tú sabes muy bien cómo es Bogotá, o sea, Bogotá es una ciudad que es bien caótica, todo el mundo está en lo suyo y uno pues necesita… necesita tener una red.” [But to be a mother … you need a network … because who else is going to teach you if is not your own mother … or your female cousins, or your aunties? … Especially here … in this city where everything is so, so, so … chaotic … everybody is doing their business … and so … one needs … to have a network].

Responsibility taken by love. “Ese primer parto para mí fue como el logro, el sueño de poder decir “estoy acompañando una madre de un hospital”, pues del POS, ¿sí me entiendes? eso para mí, yo creo que ese era, después de tantos años, era lo que yo realmente había visualizado y había querido, que era poder decir que ya estaba trabajando en un hospital. ¿Cómo podemos decirlo? no público, sino un hospital en la que estaba prestando el servicio porque el hospital lo estaba ofreciendo, y no era porque era privada, no era porque me pagaran a mí.” [That first birth for me was like the achievement … the dream of being able to say “I am accompanying a mother in a hospital', so … do you get me? That … for me … I believe that was, after so many years, what I was envisioning and had wanted … being able to say that I was working in a hospital. How can we say it? Not a public one … but a hospital in which I was offering a service because it was offered by the hospital and wasn't because it was private … it wasn't because they were paying me for it].

Learning from experience. “Tuve una lactancia demasiado difícil, difícil por muchas situaciones, ahí también encontré que había demasiadas falencias en cuanto a la asesoría de lactancia, los acompañamientos de lactancia por parte de las enfermeras, por parte de la misma pediatra que no tenía ni idea y mi, mi preparadora D., que era muy buena y tenía mucha experiencia con partos, le faltaba información en lactancia materna, y estuve a punto de unas mastitis muy fuertes hasta que como hacia los cuatro meses.” [I had a hard time with breastfeeding because of many situations … I found a lack of breastfeeding guidance … breastfeeding companionship by nurses … by pediatricians who had no idea, and my … preparer D … who was very good and had so much experience with births … lacked information on maternal breastfeeding … I got mastitis …].

Doula's Practices

Reliving fear. “El primer parto que acompañé como profesora de yoga en realidad fue de una amiga mía, una amiga mía que conocí y ayudé, de Ibagué y está embarazada, y ella me dijo “L., yo quiero que me acompañes porque el papá del bebé es supernervioso.” [The first birth I accompanied … as a yoga teacher, was actually of a friend of mine … a friend of mine who I met and helped from Ibague and is pregnant, and said to me “L … I want you to accompany me because the baby's father is super nervous].

Instinct. “Yo estuve como acompañante de ella todo el tiempo, haciéndole masajes, no sabía nada de doula, o sea nada, era como que muy instintivo, de masajes, acompañándola, respirando, haciendo movimientos, era una cosa más, más instintiva que saber realmente lo que hacía.” [I was the companion all the time … giving her massages … I didn't know anything about doula … nothing … I mean, it was very instinctive … massages … accompanying her breathing … making movements, it was instinctive rather than really knowing what I was doing].

Providing support. “Simplemente soy una mujer que apoyó a otras mujeres y a otras familias, una mujer que siempre estuvo apoyando a madres y a familias. Que fue un agente de cambio porque yo considero que ser agente de cambio es importante.” [Simply … I am a woman who supported other women and other families … a change agent … I consider that being a change agent is important].

Accompany. “Una doula es una mujer que apoya, acompaña a otra mujer o a una familia en todo el proceso del embarazo, el parto y el posparto, y cuando hablo de acompañamiento, porque es que podría extender demasiado el término, pero yo digo que acompañar y apoyar es como los sino… los verbos que pueden definir como mucho nuestro acompañamiento.” [A doula is a woman that supports … accompanies a woman or a family throughout the pregnancy, birth, and postpartum process … and …when I talk about accompanying … I say that accompanying and supporting is like … the verbs that define our companionship].

Informing. “Entonces empecé a buscar información, digamos, que para todas esas parejas que me escribían donde casi que llegaban a Colombia ya con una información específica que yo les daba, recomendaciones de médicos, recomendaciones de clínica, recomendaciones de todo.” [Then I started looking for information … let's say, for all those couples … when they arrived … they already had the information that I gave them, recommendations on physicians, recommendations on clinics, recommendations of everything].

Sharing the knowledge. “hacemos unas certificaciones de doula con Doula Caribe porque digo “bueno, sí necesitamos que se mueva el Doulaismo en Colombia pues necesitamos más doulas”, y hago una gran certificación y terminamos reuniéndonos muchas mujeres que hacíamos de uno u otra manera este trabajo desde muchos años, pero todas desde educadoras prenatales o acompañantes de parto, pero no con el nombre como tal doula” [We have doula certification with Doula Caribe … I said, “Ok, … we need Doulaism … in Colombia … we need more doulas”, and I created a certification … we ended up meeting so many women that were doulas in one way or another way … for so many years … but everyone as prenatal educators or birth accompanier, but not with the given name of doula].

Managing the pain and fear “Bueno, ya estás en 8, nos vamos a la casa” (ríe) pero él siempre me decía que hasta que no me veía en el piso no creía que estaba de parto, y yo “pero, por qué?” me decía “porque no puedo creer que seas una mujer que no, que no te duela” y yo “a mí sí me duele, lo que pasa es que pues respiro un montón y no significa que no me doliera”, ese parto dolía pero era diferente, yo como que aceptaba más ese dolor.” [“Well, you're already at 8 (centimeters), we're heading out from home” … but he always told me … that he doesn't believe I was delivering and I was like “but, why?”, he said “because I can't believe you are a woman who doesn't, who doesn't feel pain” And I “I do feel pain, what happens is that I breath a lot and it doesn't meant it doesn't hurt” … that delivery hurt … but it was different, I was like accepting that pain].

Comfort and movement. “En el trabajo de parto yo todo el tiempo dándole las medidas de confort a la mamá, como masajes, acupresión, recordarles la respiración, recomendarle movimientos, posturas, darle de comer, hidratarla, o sea, consentirla completamente todo el tiempo junto con el papá, si?, en el momento del expulsivo, le ayudo muchísimo en la parte del expulsivo, con los doctores que trabajo utilizo mucho la técnica del rebozo como para motivar el que el expulsivo sea mucho más chévere y que la mamá sepa dónde debe pujar, que se sepa bien dónde tienen que pujar cuándo.” [During the birth labor I am always giving to the mother the means for comforting, such as massages, acupressure, reminding her to breath, suggesting her movements, positions, feeding her, hydrating her … pamper her all the time together with the father … In the crowning stage, I help her a lot regarding the expulsion, along with the doctors I work with … I utilize a lot the rebozo technique to make the expulsion more amenable and for the mother to know when she must push, for her to know well where she has to push when].

Getting Rid of Her Fate by Means of Her Will

Gender stigma. “Mi abuela… bueno, la historia de ella es, es una historia bien fuerte, es una mujer que era una campesina y ella e… pues nada, en, en ese tiempo, pues una de las visiones de la mujer era casarse, tener su esposo, parir muchos hijos y la crianza” [My grandmother… well, the story of hers is, is a shocking story … is a woman who was a Farmer and she … in that time … one of the woman's visions was to get married, have a husband … give birth … so many children … and raising them].

Being a mother. “Mi abuela era como el centro, entonces era maravilloso, ay yo me sentí super bien porque era reunirnos todo el tiempo, todo el tiempo, con todos los situaciones que tiene las familias, obviamente, pero ella era el pilar y todos alrededor pendiente de ella e… y mis tías que obviamente traían a todos sus nietos para que ella los cuidara y ella recibía a todos, a todos “vengan pa' acá”, ella era la más feliz con todos los nietos, era lo máximo esa experiencia de estar ahí en casa con ella.” [My grandmother was like the center … then it was wonderful … I felt pretty good because it was about being together all the time … with all the situation that families have … obviously … but she was the cornerstone and everybody around was attentive to her … my aunties … took all the grandchildren for her to take care of them … she welcomed all of them … all … “Come on” … she was the happiest … with all the grandchildren, such an experience of being at home with her was the best].

Women empowered. “Cuando uno siente que ya dio a luz a un bebé, a un ser vivo es como que… y lo que yo te decía, antes o después de parir un hijo uno siente que puede solo contra el mundo, es una experiencias muy empadronador.” [When one feels that one gave birth to a baby … to a living being … is like… what I said … before or after having a child one feels like one can make it against the world … it is such an empowering experience].

Facing adversity. “Pero mi recuerdo es como de los, como de tres años aun tratando de sobrellevar las cosas, ya mis tías más grandes, mi mamá, todos trabajando e… pero siempre tratando como de salir adelante” [But my memories are from them … I was three years old yet trying to endure the situation … my aunties were already grown … my mom, everybody working … always trying to get over it].

Finding the path. “Si bien, estaba la idea de que quería estudiar porque entonces yo les llamé a M. y le dije “Yo quiero trabajar, quiero saber dónde puedo estudiar” entonces me dice “pues para hacer lo que hace D. tienes que ser del área de la salud”, y yo “pero es que yo no quiero ser médica, ni doctora, ni enfermera, pero yo quiero ser doula”, me decía “L. eso no existe en Colombia, la profesión de la doula no existe y para ser doula tienes que irte a España” lo más cercano que encontramos, era como España” [… I want to study … I called to M. and I told him “I want to work, I want to know where I can study” … he said “So to do what D. does you need to be from the health care area” … I said, “But I don't want to be a physician, or a doctor, or a nurse, I want to be a doula,” he said to me, “L … that doesn't exist in Colombia … the doula profession doesn't exist … to be a doula you must go to Spain” … that was the nearest place that we found, it was Spain.”

The Doula in Action

Gratitude to life. “Pues sabes que no enfrente ninguna dificultad porque yo siento que…que yo fui tan feliz en mi infancia con las cosas que me dieron ellos (abuelos), porque, aunque no eran lujos era… pues nada… era tenerlos a ellos, era tener la casa, yo fui muy feliz en mi infancia” [You know … I never faced any difficulties because I feel that… that I was so happy in my childhood with the things that they (grandparents) gave me … because … despite no luxuries… that's it… it was having them … it was having a house … I was really happy in my childhood].

Having a dream. “Y en ese momento había un programa de televisión, no sé si te acuerdas, que daba unos programas de partos y yo veía esos partos en el agua y pues yo dije “yo quiero parir así …”. Nada, no, no, cual? eso no existe en este país, eso aquí no existe” [And in that moment there was a TV channel … I don't know if you remember … that shows … births and I saw those deliveries in the water and so I said “I want to give birth this way….” … Nothing, no, no, what? … That doesn't exist in this country … that thing doesn't exist here].

Being understood. “Porque hay veces uno siente que hay alguien que lo juzga y le dice “pero esto o qué estás pensando?” o…otros decían “estás loca porque eso aquí no va a pasar, ni va a existir nunca” [Because sometimes there are moments in which one feels there is someone who judges you and says … “What are you thinking?” or… “Others say you are crazy because that thing is not going to happen here, and is not going to ever exist”].

Being the first. “Cuando me presento y digo que voy de Colombia fue como “Colombia? Y donde queda Colombia? Donde es ese país? De América?” bueno en fin, era como nadie tenía ni idea, no había una referencia como tal de doulas ni de nada, entonces yo me sentía super orgullosa porque decía “bueno, voy a ser la primera realmente certificada, que va a llevar un certificado”” [When I introduced myself and said that I'm from Colombia that she was like “Colombia? Where is Colombia located? Where is Colombia? Is it in America?” … Well ok … that was like no one had any idea … there wasn't a reference about doulas … about nothing … then I felt so proud because I said “Well, I'm going to be the first certified one, who is going to bring a certificate”].

Doula challenges. “Entendí el contexto de que las doulas en Suramérica no fueran tan aceptadas dentro del medio, dentro del área de la salud, porque no se aceptaban, entender que era casi un reto llegar a Colombia a buscar el espacio y empezar a trabajar” [I understood the context in which doulas in South America weren't so accepted within the environment … within health care … because they weren't accepted … understand that was almost a challenge to arrive in Colombia to look for a spot and begin to work].

Building bridges. “Yo siempre he sido demasiado cuidadosa y respetuosa del proceso, porque siempre he sentido que… siempre creí que mi trabajo no era llegar a pelear con el sistema, sino más bien entrar muy suavemente reconociendo la labor de cada uno” [I always have been extremely careful and respectful of the process … because always I have felt that… always believed that my job was not to arrive to fight the system, but rather enter so subtly … recognizing everyone's job].

Bad practices. “Las malas prácticas hicieron que el Doulaismo se viera mal, si? se viera como que venimos aquí a pelear contra el sistema, pero eran realmente algunas malas prácticas” [… Bad practices made Doulaism frowned upon, didn't it? Like we came here to fight against the system, but there were actually some bad practices].

Healing wounds. “Estuve tres semanas hospitalizada, no me podía mover nada, porque me daban esas e… cómo se llaman? esas contracciones se me activaban y era el susto y el miedo de que ya rompiera fuente, o lo que fuera y estuve hasta la semana 35 hospitalizada, tres semanas hospitalizada súperbien, bien atendida, simplemente esperando, esperando a que el cuello no se cerrara porque no se iba a cerrar pero que se durmiera ese útero” [I was hospitalized for three weeks … I couldn't move … because … contractions … and … the fear of water breaking … and I was hospitalized until the 35th week … pretty good … well assisted … just waiting … waiting for the cervix to close and contractions to cease].

All of these categories can be encompassed in the main theme A calling from within: Growing up to accompany the transition from woman to mother. L decided to become a doula driven by her experience of maternity, and by the inspiration from her role models.

“Enterarme después de muchos años que mi abuela terminó siendo partera por el hecho de que en el campo al haber parido tantos hijos la convertía en una mujer que tenía experiencia, entonces la terminaban llamando a ella (…) me pareció increíble saber cómo ella, cuando ya llegó a la ciudad, entendió que ya no era su trabajo hacerlo porque ya en el pueblo ya había un hospital (…) Me pareció bonito, eso me parece importante que ahí siento, que ahí había una semilla, siento que eso (ayudar mujeres) en el ADN tuvo que estar” [Finding out after so many years that my grandmother ended up being a partera just because in the countryside … having given birth so many children, makes her a woman that had experience … then they ended up calling her (a partera) … It was amazing knowing how she … when arriving in the city, understood that being a partera wasn't her work anymore because there was a hospital in town … that was beautiful for me … I think that is important … I feel, that there had been a seed … I feel it (helping women) had to be in the DNA”

DISCLOUSRE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.