Things You’ll Never Hear Me Say as a Specialist Doula, Pt. 3
I hope you’re ready for something nerdy! This week’s blog post is the third in a four-part series on things you’ll never hear me say as a doula who specializes in supporting folks who are pregnant after experiencing infertility, loss, birth trauma, or with medical complexities. The last two posts I did on this topic had more to do with how we conceptualize birth (as ‘natural,’ ‘beautiful,’ or as a bodily process that we should encourage people to unequivocally trust). Today, I’m going to be talking about something a little bit different, which is how we use knowledge or information in our role as doulas. As always, pointing to these differences between how I practice and how I’ve seen other doulas practice is never meant to shame or belittle the practice of other doulas. Rather, I believe that different clients benefit from different practice approaches and sharing my unique approach with you allows you to make better decisions about who you want to support you through your birth. Maybe you read through my blog posts and get a visceral, “yes, this is exactly the doula for me.” I’d love that. Hit me up. But maybe the vibe you get is a no; that’s okay too! You get to choose the people you recruit for your ultimate birth dream team. That’s where the magic is. So, what’s up this week for “things you’ll never hear me say as a specialist doula?”
“The evidence on (x) is (y)” – without qualifiers!
Okay, Brooke, what the heck does that even mean? Let’s begin with an example. You’re a pregnant person and you want to learn more about 39-week inductions. Your doctor is really encouraging you to consider being induced at 39 weeks, but you just aren’t so sure. You know that an induction might set you up for having other interventions that you’d rather avoid in your birth and so you ask your doula about it. Now, many doulas these days are really interested in something called ‘evidence-based medicine’ or ‘evidence-based’ practice. Evidence-based medicine (EBM) emerged only fairly recently as a style of practicing medicine that wanted to move away from physicians making judgments about the best care/treatment for patients based on their clinical experience and, instead, look at what the research evidence says about the effectiveness of different treatment options to help make decisions about what doctors (and their patients) should do. And in truth, it’s a really cool idea. For folks who were concerned that doctors were making decisions based on “well, that’s what I’ve always done,” the idea that we could instead see ‘proof’ that something works or doesn’t work before we decide to put ourselves through a treatment protocol is really appealing. And in the world of obstetrics – where doctors help people birth babies – many doctors, nurses, and doulas believe that EBM is the way to go because it is supposed to focus on what actually works instead of using old-school interventions that aren’t needed but are frequent contributors to birth trauma (ex: episiotomies). In truth, using EBM principles and research briefs can be a really helpful tool for birthing people who would like to engage in better conversations with their health care providers about their care options. Anyone who has used the “evidence-based birth” (EBB) podcast, pocket books, or articles in their practice (as doulas) or to help guide their decision making as a birthing person, has used EBM materials! So your average EBM-loving doula is going to hear your question about 39-week inductions and say, “hey, I can help you there! Here’s this research brief that says 39-week inductions aren’t necessary.” Or something to that effect. It seems like a simple way to answer a question.
A translucent model of a human skull, showing the complexity of the human body.
So why, if this is supposed to be a great and useful tool, do I not regularly talk about the research evidence without qualifiers? There are plenty of reasons that I could drone on and on and on about (trust me, this is my academic area of interest and I can get really boring), but today I’m going to keep it simple and talk about just two reasons:
There are issues with translating statistical data – which is based on the rate at which something happens within a standardized population of people – to the case of individual clients. The best and easiest example here is made obvious by looking at something called ‘exclusion criteria.’ When researchers design their studies – for example, they want to know about the outcomes for birthing people and babies when labour is induced at 39 weeks versus when we wait for people to go into labour spontaneously – they have to begin by defining the population of people that they’re going to study. Because researchers want to make sure that there aren’t any outside factors that are influencing their findings, they’re really choosy about whose information gets used in the study. Most often, research studies looking at birth interventions and outcomes exclude anyone who isn’t having a ‘normal,’ ‘healthy’ pregnancy. They do this so we can get baseline information about how the intervention alone (not in combination with other factors) influences outcomes. But that also means that the information we get from that study does not tell us about whether the results would be the same if we use that intervention for someone who is having a ‘high risk’ pregnancy. So, if I’m working with a client who is labelled ‘high risk’ because they conceived their pregnancy via IVF and they have gestational diabetes, I can tell them what the research says about 39-week inductions for people without these issues, but the research doesn’t give me enough information to know whether it applies to my client or doesn’t. Maybe it would be the same, but maybe it wouldn’t. That doesn’t mean that we don’t ever have evidence-based information that we can share with birthing people to help them make decisions about what they want to do, but if we’re looking for specific studies that exactly match the factors our clients are negotiating, we might not find studies that are a perfect fit or they’re much more likely to be smaller, “poorer quality” studies.
Research evidence only gives us part of the picture. Because of what I just talked about above – how researchers have to do specific things to make sure outside factors don’t influence their research results – it also means that research evidence, at least quantitative evidence based on statistical information, takes interventions and outcomes out of context. It’s complicated, but let me put it this way: you are not a number. You are not one factor or one facet of a human life that we can directly study to know if something is going to work or not. You’re complex. You have a unique health history, a biology that has its own quirks, you have different preferences and experiences that mean how something works for you or makes you feel is actually going to be the result of a whole mess of things that work together. Your birth is never going to be the result of a 39-week induction alone. Birth outcomes are the result of a lot of other forces that work together. And what’s more, outcomes that we can measure (ex: whether or not an episiotomy gets performed or how much blood volume is lost by the birthing person after birth) aren’t all that matter either. Things like how someone feels about their birth experience, whether they felt supported to make the decisions that feel right for them, how something that happened in the birth room impacts their self-esteem for years to come… those kinds of things are much harder to quantify and study. But they also really matter! My point is this: people are allowed to make decisions based on what feels right for them, even if the “evidence” isn’t there to tell them that it’s the right thing to do. And, because we’re so complex as people, the evidence isn’t ever going to give us the full story anyway, so we have to use other pieces of information to help us decide on a course of action.
So, do I use evidence-based information in my work as a specialist doula? Sure. However, I never use that information without a more detailed conversation about how the evidence was made, why it may or may not apply to the unique individual I’m working with, or without asking my clients about their feelings about it. What is your gut telling you? Where are those feelings coming from? Further, sometimes we can plan to avoid something because it doesn’t seem to be supported by the evidence but then something unexpected happens that the evidence is no longer valid, and we now need that thing we thought we would avoid. When circumstances change, so too does our relationship to the evidence that we’re using. And so, it can be helpful to look at, “if something changed and this became a part of your story, what can we do to make that a better experience?” Evidence-based information can be a wonderful tool that birthing folks can use to have incredible, thought-provoking, and empowering conversations with their providers. It can help us to better understand birth processes and get a sense of why a certain intervention may or may not be used, so that we’re more informed if something comes up. But at the end of the day, it’s always about having the conversation about how that information fits into your life, your wishes, and your story. It’s never, “the evidence on X is Y, so you should do Z.” And, if you have a super nerdy doula who is willing and able to hash it out with you, it can further put you in a better, more informed position during a hugely important time of your life.
If that sounds like something you’re looking for from a Calgary birth doula, you can set up a free virtual consultation here and check out my birth packages here.