Doulas in Italy

The Emergence of a 'New' Care Profession

Pamela Pasian

• Publisher: Taylor & Francis
• Year: 2022
• eBook ISBN: 9781000579772
• Edition: 1
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

This book documents the emergence of doulas as care professionals in Italy, considers their training, practices, and representation, and analyses their role in national and international context. Doulas offer emotional, informational and practical support to women and their families during pregnancy, childbirth and the postpartum period. Pamela Pasian explores the development of this 'new' profession and how doulas are defining their space in the Italian maternity care system. Whilst doulas are gaining recognition they are also facing opposition. The book reflects on the conflicts and collaborations between doulas and midwives, as well as relations between different doula associations. Interweaving ethnography and autoethnography, it will be of interest to anthropologists, sociologists and those working in health and maternity care.

1Doulas: From their origins to their present status

DOI: 10.4324/9781003165934-2

The origin of the word “doula”

As noted in Introduction to this volume, the first author to introduce the word “doula” was Dana Raphael in 1966. Raphael, an anthropologist and pupil of the famous anthropologist Margaret Mead, devoted her PhD research to the topic of breastfeeding in different cultures and in some animal groups. Raphael (1966) affirmed that her personal failure to breastfeed her first child stimulated her interest in studying varying experiences of motherhood, in order to understand what factors could influence breastfeeding success. Her work identified the common denominator for success in breastfeeding, which consists of some degree of help for the new mother, from some specific person, for a precise period after childbirth. Raphael discovered the presence in many cultures and animal species of such a support figure. She highlighted how this role was occasionally covered in the U.S.A. by a figure called “auntie”; however, she considered this term unsatisfactory for describing the systematic support to the new mother that she had observed in other cultures and in animal groups. Instead, she decided to identify the profile that fulfills these functions with the word doula (Raphael 1969).

Raphael noted that the term doula is of Ancient Greek derivation: δoúλŋ (in Modern Greek δoúλa), a female noun indicating a slave or servant. According to Raphael, in the 19th century, the negative meaning of the word disappeared and the term δoúλia (doula) was used in an honorific sense and distinguished Greeks and Christians from Turks or “infidels.” The word doula thus acquired an aura of respectability that was later lost again. At that time, in the 19th century in Greece, the term was used to denote a woman who assisted a new mother by supporting her in housework and with children. The doula could be a neighbor, a relative, or a friend who voluntarily supported the woman for a limited period of time (Raphael 1969).

Raphael does not include any bibliographical references in her writings in relation to the origin, the meaning, and the positive sense that the term doula might have acquired at the end of the 19th century. The sole information in this regard was provided on the website of the Human Lactation Center,¹ which Raphael founded with Margaret Mead in 1975, where Raphael stated that a Greek woman, who had immigrated to the U.S.A. at the beginning of the 20th century, suggested the term doula and described her specific role.

In order to verify the reliability of the Raphael’s statements about the positive meaning acquired by the word doula in the 19th century, I got in touch and started an intense correspondence with Maria Andreoulaki, Co-Founder and Coordinator of the Educational Committee for the Doula Certification program in Greece through the Greek Doula Association. Andreoulaki represented the Greek Doula Association during the European Doula Network (EDN) meeting, held in Portugal in 2014, giving a lecture entitled “Doula: from an ancient Greek word to a modern international reality.” Andreoulaki, who conducted a great deal of research to understand the origin of the word doula, considers unlikely the positive 19th-century meaning attributed to the term by Raphael. Andreoulaki hypothesizes a possible misunderstanding between Raphael and the elderly Greek woman for two main reasons. First, Greek emigration at the end of the 19th century was characterized by poor, often illiterate people fleeing post-war crisis, civil war, and very poor living conditions, and consequently, according to Andreoulaki, the elderly woman’s command of English could not have been sufficient to allow an accurate description of the doula profile. Second, Greeks were allegedly called “slaves” by Turks, and the word doula could indeed possibly have been a reassuring means to define themselves as Christians. Raphael decided, perhaps incorrectly, to rely on the story of the elderly woman. And considering the correspondence between the doula functions described by that woman and the activities carried out by the support figures present in the cultures and animal groups she investigated, Raphael (1973:172) chose to adopt the term doula to define “one or more individuals, often female, who give psychological and physical assistance to the newly-delivered mother.”

The term proposed by Raphael was later embraced by influential researchers Marshall Klaus and John Kennell (as I will describe later on), who expanded its meaning to define a doula as a woman experienced in childbirth assistance who provides information and continuous physical and emotional support before, during, and immediately after the delivery, thus enshrining the current definition of the term doula. It is interesting to note that this word and its related profile were initially established in the U.S.A. and Europe and gradually spread worldwide. According to Andreoulaki, the only country in the world where the word is considered unacceptable and unusable is Greece, where the term maintains its negative connotation of servant or slave. However, during international meetings, Greek doulas adhere to the widespread use of word doula to represent themselves.

The international development of the doula

The development of doulas in the U.S.A.

The doula emerged in the U.S.A. between the 1980s and 1990s in response to the changes in the medical and social contexts of birth that had been occurring (Morton and Clift 2014). From the 1930s to the present, the U.S.A. experienced a succession of controversial processes: the hospitalization and medicalization of childbirth have over time been countered with the birth of movements aimed at promoting women’s health, patients’ rights, the demedicalization of labor and birth, and the use of non-conventional medicines. A number of patients’ rights organizations were set up to develop advocacy activities aimed at satisfying women’s wishes related to medical practices involving their bodies. According to Davis-Floyd (2022), from an earlier focus on “natural childbirth” and “alternative birth,” the adoption of a rights-based humanistic paradigm in the biomedical–hospital–technocratic context became the objective to be pursued (Davis-Floyd 2001, 2018; Earp et al. 2008).

In those same years, scientific evidence on the importance of the doula’s role in childbirth was consolidated by the work of neonatologist Marshall Klaus and pediatrician John Kennell and their numerous studies (Klaus et al. 1986, 1993; Kennell et al. 1991). These two researchers, interested in investigating factors that inhibited or favored mother–child bonding, discovered the figure of the doula described by Raphael (1973) and decided to adopt it as an explanation of the results that emerged from their earliest studies. The incident that marked their introduction of the term took place in a hospital in Guatemala, when a medical student who was collaborating with these researchers and their team never left women alone during labor. Her role should have been to stay true to the purpose of the study—the goal of which was to investigate factors that inhibited or favored mother–baby bonding—but she accidentally remained continuously next to every woman in labor to whom she was assigned for this research project. This was interpreted as a mistake and the ten mothers she had supported were excluded from the study. However, it was later decided to examine the data of the ten women previously excluded, and it emerged that their labors had been unusually short and without complications, and in three of them, there had been a very rapid production of colostrum after childbirth (Klaus et al. 1993). This fortuitous event inaugurated a series of studies carried out in different contexts, which confirmed that the continuous presence of a support figure, called a doula, reduced the number of caesarean sections by 50%, the duration of labor by 25%, the use of pitocin to augment labor by 40%, the use of analgesics by 30%, the use of forceps by 40%, and the demand for epidural analgesia by 60% (ibid.). These convincing results provided a solid scientific foundation for the introduction of the doula into the labor room, thereby helping to create an entirely new profession in the U.S.A.

The first doula trainings in the U.S.A. ran between 1979 and 1980 in The Birth Place, a freestanding birth center founded in 1979 in Menlo Park, California. The trainings, taught by various people with differing skills and perspectives that included the integration of mind, body, and spirit, and dealt with political issues and the history of birthing, were organized twice a year and were not well structured. In 1983, one of the trained doulas, Rahima Baldwin, decided to found an organization called the Association of Childbirth Assistants, which in the following year became the National Association of Childbirth Assistants (NACA). NACA later evolved into the still-extant ALACE—the Association of Labor Assistants and Childbirth Educators.

During the 1980s, the doula profile began to spread in the country, to receive more attention among childbirth professionals, and to be the subject of publications. Since then, numerous doula organizations have been formed at local, national, and international levels. In 1992, the Doulas of North America (DONA) association was founded by neonatologist Marshall Klaus, pediatrician John Kennell, psychologist Phyllis Klaus (Marshall’s wife), perinatal educator Penny Simkin, and doula Annie Kennedy. The first goal of these founders was to create an umbrella association able to define the training paths to becoming a doula in order to homogenize and certify the doula training programs that by then were spreading across country with considerable variations. Despite the fact that numerous doula associations decided not to merge into DONA, the association grew considerably as the number of members increased, and the use of the term doula started to be implemented and nationally recognized, thanks to specific trainings and advertising events, and to the personal reputations of the founders, who were and are still widely admired in the US birth activist community, which considers them to be “icons” and “culture heroes,” both in life and in death (as Marshall and Phyllis Klaus and John Kennell are deceased). In 2004, having expanded its reach beyond the U.S.A., the association changed its name to DONA International. By September 2021, DONA International trained more than 12,000 doulas in 50 countries of the world and constitutes a reference point worldwide (www.dona.org).

Interestingly, an early controversy that arose between the founder of what later became ALACE, Rahima Baldwin, and the founders of DONA was whether or not doulas should be allowed to perform cervical checks to assess dilation at the laboring woman’s request, usually to help her decide when to head to the hospital. According to Robbie Davis-Floyd (personal communication, September 2021), Rahima Baldwin was adamant that this should be part of doulas’ skillset, while DONA was equally adamant that it should not. Since cervical checks carry dangers, such as infection, and are considered medical procedures that should only be performed by midwives or doctors, this controversy was ultimately resolved in favor of doulas not performing them. Thus, doulas learned many other methods of assessing labor progress, such as the sounds the mother makes, how she smells and acts, the kinds of breathing she does, and certain bodily changes. These skills matter most if the mother-to-be is laboring at home and needs to decide when to go to the hospital. Going too early, when she is still in latent labor, which can safely take hours or days to turn into active labor, can result in many interventions, a diagnosis of “failure to progress,” and a cesarean birth. In the U.S.A., the doula’s role has come to include going to the mother’s home when labor begins, and helping her to decide when it’s time to go to the hospital—should she be planning a hospital birth.

The development of doulas in Europe²

By the early 2000s, doulas had begun to proliferate in Europe, and new doula associations rapidly arose. In 2001, Doula UK was established in Great Britain, and in 2006, the association Doulas de France in France. In 2008, Doulas in Deutschland was born in Germany; in 2009, Eco-Mondo Doula³ in Italy⁴; and in 2010, AED—Asociación Española de Doulas in Spain.

In 2005, a few European doulas started to share the need and the vision to establish quality standards for doula training and practice; reflections and discussions continued during a conference in Graz, Austria (2006), and at several birth-related conferences, including Midwifery Today conference in Bad Wildbad, Germany (2006 and 2008), and at a conference in Paris, France (2007). With the goal of creating a network of support and information among the various doula training providers and associations in Europe, this group of European doulas undertook a six-year path. In 2006, the association Doulas de France set up a Yahoo site with the idea of generating a focal point where doulas could network and included in their ...

Table of contents

• Cover
• Half-Title Page
• Series Page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of figures
• Foreword
• Acknowledgments
• Introduction
• 1 Doulas: From their origins to their present status
• 2 The emergence of doulas in Italy
• 3 Keys for studying the doula profession
• 4 Doula training
• 5 The doula profession
• 6 Doulas and midwives
• Conclusion
• Bibliography
• Index