Midwifery Today E-News, June 6, 2018 • Volume 20, Issue 12
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Birth takes us to the way between worlds—the portal—and the midwife’s respect for birth as an altered state is yet another offering to those she serves.

—Elizabeth Davis, in “Prenatal Care: What Really Matters?” in Midwifery Today Issue 124, Winter 2017

Inside this issue:

This issue is brought to you by:

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Jan’s Corner


I have been thinking about the most pressing issues facing midwives globally. I know that, for us in the US, autonomy is a key issue, and I think it is for midwives everywhere. Midwives cannot function to their full capacity without it. When I asked about it on my Facebook page, a friend said: Autonomy makes you accountable to those you serve. Midwifery without autonomy makes you answer to physicians, the hospitals that own the physicians’ contracts, and nursing boards that want to control midwives.” Barbara Harper said, “Being a guardian of birth means respecting and supporting the innate physiological processes and biological imperatives of both mother and baby.” The bottom line is that mothers need autonomy for midwives and doulas to have it.

We have suffered too much interference from the powers-that-be and from protocols unsupported by any evidence. As another Facebook friend, Enza Cicero-Lilley, said, “As a doula, it’s watching so many clients being induced for absolutely no reason at all. I give science-based information for everything and then the OBs tell them that if they don’t listen to them, their babies will die. And every couple of months, it changes. For a while, it was “everyone had low fluid,” then it was “big babies,” and currently it seems to be ‘you are almost 40 weeks, so placental deterioration may be occurring.”

With true autonomy there would only be the mom, her partner, and the midwife to make decisions. Women feel more empowered if they are part of the decision-making process. Empowered mom equals better parenting, with less trauma even if the birth doesn’t go as planned. I do not know how to change the horrendous birth practices paradigm we have but we all must keep trying.

I hope that Margaret Mead was right when she said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” We are all sure trying! Please keep it up, all Toward Better Birth!

—Jan Tritten

Jan Tritten is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.

Plan now to attend our conference in Bad Wildbad, Germany, this fall!

“Birthing in Love Changes the World” will feature teachers such as Michel Odent, Gail Hart, Debra Pascali-Bonaro, Elaine Stillerman, Elizabeth Davis, and Tine Greve. Planned classes include Rebozo Techniques and Practice, Sustainable Midwifery, and Hemorrhage. Learn more and register.

Pediatric Medical Professionals Support the Flexmort CuddleCot™

The CuddleCot™ keeps a stillborn baby cool in a bassinet next to the mother. Over 700 hospitals across North America are using the CuddleCot™. Tyler Sexton, Chair and Medical Director of the Pediatric Program, Singing River Hospital, Mississippi, comments, “The CuddleCot provides a longer bonding experience for families as it provides some time for closure….” For further information visit our website.

The Farm Midwifery Workshop Program

Come learn from our world-renowned midwives and join us in classes for doulas, midwifery assistants, midwifery students, midwives, nurses, doctors, and medical students.

  • Midwifery Assistant Workshops
    Aug 26 – Sept 1, 2018; Nov 11 – 17, 2018
  • Advanced Midwifery Workshop
    (CEUs applied for) July 29 – Aug 4, 2018

E-mail us or visit our website.

Country Contact Q&A

Editor’s Note: Midwifery Today is interested in promoting international networking among childbirth practitioners. Our goal is to strengthen the international community by establishing a country contact in every country of the world. If you would like to become a country contact, please e-mail Jan Tritten.

For this international edition of E-News, we asked Midwifery Today’s country contacts the following question:
Are doulas used in your country? If so, please describe their role.


There are no doulas in Belize. A labor companion is allowed, in policy, but does not happen much. Plus, the companion is not trained; there are no childbirth classes; women are not, as a whole, assertive; husband and grandmas are not, either. Culturally, it’s like 1950s America here as to birth practices. The c-section rate is high because of lies, in most cases, and women thinking the doctor knows best. Women must still have legs in slings, back flat on a table, birth with no companion, episiotomies, verbal abuse, “push-push-push,” bathing babies, early cord cuttings—all copied from USA’s old and still-used policies.

—Gail Johnson

South Africa

Irene Borquin is the pioneer midwife who began training doulas in South Africa in 2001 and now we have wonderful doulas in every major city in South Africa. When I started practicing as a midwife in 1982, doulas were unheard of and I was the doula, the midwife, the mother caring for the woman in labour. I first read about doulas in the work of Dr. John Kennell and Dr. Marshall Klauss in 1984/5. Dr. Kennell said that if doulas were a drug it would be unethical not to use one!

It was only much later in 2001 that I was accompanied by doulas to births, very often as part of their training. And then, once I realised how good it was for both the mother and the midwife to have a doula present at the birth, having a doula became the golden rule.

—Marianne Littlejohn

Costa Rica

Yes, in Costa Rica doulas are used in private hospitals and in some midwife practices. There are quite a few doulas working in San Jose (the capital), I am not so sure about the provinces. Doulas are not permitted in the public hospitals, which are run by the public social security system. Things have changed a little there and they are more mother friendly and not so routinely doing episiotomies as before, but some OBs are still pretty abusive with the women. Also they are clamping down on vaccine obligation control and you cannot register a baby without proof of the first vaccines (but we always find a way around).

—Uva Meiner


We generally don’t use doulas in great numbers in Australia or New Zealand. In New Zealand, we have lead maternity carer midwives. These are independent midwives who offer continuity of care to women across the spectrum from homebirth to tertiary birth. Doulas are an emerging phenomenon there, apparently especially in the postnatal area.

Australia is in earlier stages of independent midwifery, but all women will have a midwife support them through their labour and birth. These will mostly be midwives employed by the hospitals, or midwifery group practices. That said, there are doulas who offer amazing service to women. A doula is common among Aboriginal people, and a growing number of women of all races is looking for the nurturing and support that a doula can offer. There are now a number of websites offering their services, and the media is supportive. It was around 2004 that many more women started to ask for birth support, and to look for doulas. It is believed that this was in response to the high intervention rates and the medical model of birth in Australia.

—Alison Higgs


Doula Delight was the doula service in Freeport, Grand Bahama, which put the Bahamas on the list of countries offering birth doula care. The paternalistic nature of health care in this commonwealth has stifled the staying power of any birth doula or birth doula group. In Freeport, birth doulas have been banned from the one public hospital (Rand Memorial) “until the attorneys of the Public Hospitals Authority can determine the liability of having birth doulas support childbearing families.” Despite the volume of evidence-based, published literature that attests to the physical, emotional, mental, newborn, and breastfeeding health/health care costs and benefits of doula-supported childbirth submitted to the physicians of Freeport (Grand Bahama), the Minister of Health of The Bahamas, and the Public Hospitals Authority, the doulas of Grand Bahama are still denied entrance at the Rand where at least 95% of all Freeport births occur. Doula Delight doulas are welcome at the small private hospital that perhaps has 30 births a year, at most. The midwives have petitioned the Rand Memorial Chief Medical Officer, an obstetrician, for the return of birth doulas to the maternity ward, but the request has been ignored. Consequently, most of the public hospital births occur within obstetrically antiquated, spiritually void, and evidence-based-deficient, one-size-fits-all protocols. We, Doula Delight birth doulas, languish here.

The two birth doulas I know of in Nassau have stopped doula-ing and moved on to other childbearing related activities.

—Mary DeLashmutt


Yes, women are beginning to ask for professional doulas to accompany them while they give birth. While the very first professional birth doulas started working with women almost 15 years ago, there were just not enough of them—just a handful—and in completely different parts of the country! Also, doctors actively discouraged anyone from accompanying a mother in the labor room. Even more so, in the public hospital system. Even now, anecdotal evidence tells us that doulas are not actively being welcomed in many hospitals both public and private. But, the awareness regarding doulas is rising, for sure.

With the current WHO recommendations for respectful maternity care, and the Indian government’s own commitment to reduce maternal mortality, the government is now advocating that a laboring mother have a labor companion of her choice at all times (article). While this is not the same as having a professional doula, it is a giant first step to a better quality of birth!

Finally, even though as a country we still have a long way to go to understand fully and recognise the role of a professional doula, as women are becoming better informed, they are actively looking for doula support. CAPPA has been providing training to become a doula for a few years now, and Birth School India (an entity led by two doulas) has just begun to offer trainings to those looking to become DONA-certified doulas. With India’s cesarean rate skyrocketing—in some urban private hospitals, it is as high as 90%, and many public hospitals have a near 50% c-section rate—doulas may just be that first step needed to not only help women have an empowering birth, but also to slowly help bring unneccesareans down.

—Dr. Vijaya Krishnan


In Ghana doulas are not used. The word doula is not used in midwifery circles. Women in labor are alone in the labor ward. No labor support persons are available. The support person is the birth attendant—a midwife who has the responsibility of taking care of all the women in labor at the time. Some labor wards could have more than six women labouring together with only one or two attendants.

Family members most often accompany the woman to the hospital or birth center, but are not allowed into the labour wards due to lack of privacy. After delivery family members give support in diverse ways.

Lack of labour support for women has been my concern for some time now. I intend to initiate the concept in Ghana.

—Abena Okra


The short answer is no. The longer answer is yes, a bit, sometimes. Even 20 years ago, when doulas were unheard of in Japan, I served as a doula for couples who had taken my classes, as the hospitals they were birthing in were familiar with my work and allowed me in to support couples as a doula/interpreter, whether they were foreign or Japanese-speaking. For the past several years, a few hospitals have been open to a couple of foreign doulas accompanying their foreign clients, but it is still unheard of and unaccepted in most facilities around the country. More than a decade ago, a group of Japanese women, some of whom were non-working midwives, created a group to promote doulas. A few midwifery clinics with which they had personal ties allowed them to attend as doulas for a few clients but this never took off in a big way. There was pushback not only from OBs and hospitals, but also from independent midwives who saw the role of doula as part of their own purview. More recently, an independent midwife established an organization to train postpartum doulas, but work for the trained women is still hard to come by, as Japanese families typically do not feel comfortable having others in their homes. The concept of “doula” is very, very gradually making its way into the consciousness of Japanese society. One bilingual midwife/researcher in particular has done much to write about and promote the idea of doulas and other evidence-based birth ideas—including a Japanese version of Childbirth Connection’s Listening to Mothers, which can be found here.

—Brett Iimura

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Website Highlight

The Fourth Stage: Sharing the Asian Way
by Robin Lim

The fourth stage of labor, the time after the baby has been born (second stage) and after the placenta is safely delivered (third stage) has been defined medically as one to two hours postpartum. Culturally, I define it as the first 42 days following childbirth. I believe the fourth stage never really ends, as a postpartum woman is forever transformed by the significant rite of passage of childbirth. Read more…

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