Boundary Work in the Birthing Room: Doulas, Emotional Labour, and the Politics of Care
Building on insights from her research on midwives in Indonesia, Molly Fitzpatrick reflects on recent debates on the role of the doula in Dutch maternal healthcare.
A few weeks ago, an item on the Dutch TV program Nieuwsuur and an accompanying article in the newspaper NRC Handelsblad sparked a fierce debate within Dutch maternal healthcare. The focus of the debate was the role of the doula – a birth coach without medical qualifications, who gives emotional support during birth. While the doula originated in the US as part of the natural birth movement of the 1960s, there are now over 300 licenced doulas practicing in the Netherlands. In the recent TV item and article, three journalists set out to discover what Dutch midwives and obstetricians thought about this new caregiver joining them in the birthing room. The questioned midwives and obstetricians complained that doulas were transgressing their role of providing emotional support and meddling in the ‘medical side’ of birth attendance, with sometimes severe consequences. Especially midwives felt threatened by the doula and said that they felt that their job was being taken away from them.
Taking into account the long history of midwifery in the Netherlands, it is clear that midwives have fought hard for their current status in Dutch society. However, the midwife now appeared stuck in between the obstetrician and their medical care on the one hand, and the doula with their emotional care, on the other. With my research on midwifery in Indonesia in mind, this debate brought up new questions for me about care and the politics that surrounds it. In particular, how are the boundaries between the caring roles of different birth attendants negotiated in practice? And what can studying such boundary work reveal about the relation between the emotions and biomedicine?
Care from the Heart
My PhD research in two midwifery clinics on Bali, Indonesia, provides insight into how certain midwives draw on notions about the emotional aspect of care to challenge biomedicine. The clinics I studied had been set up by American midwives inspired by the same natural birth movement to which doulas owe their inception. These American midwives tried to apply the ideas of this movement to the local context in Indonesia, yet ran into their own version of the boundary disputes described above.
This has to do with Indonesia’s own rich history of midwifery, which many trace back to Suharto’s 1989 bidan di desa (village midwife) program. The legacy of this program are the over 300.000 midwives (bidan) that are currently spread across the archipelago and work with a biomedical protocol called the Asuhan Persalinan Normal (APN), or normal delivery care protocol. The Indonesian midwives working in the two clinics I studied had to abide by this protocol, even though they disagreed with the rigidity of the protocol’s 60 steps and the biomedical principles embedded in them. Rather than challenge mainstream Indonesian midwifery on its practices and risk losing their licences, they looked to the politics of care to find an alternative way to set themselves apart. The midwives at the two clinics on Bali often talked about their care as being dengan hati, or from the heart, while dismissing the care of government midwives and obstetricians as heartless. Through this, they placed emphasis on what Arlie Hochschild has called emotional labour as way to distinguish themselves from other care providers.
Care by Numbers
Emotional labour also plays a significant role in the Dutch debate, though it is not always recognised as such. Doulas are stepping in to provide the emotional labour that midwives do not have time to supply or, as the NRC article suggests, cannot provide because of protocols. Doulas do not have to abide by protocols as they are not a regulated profession. In fact, many doulas see professionalization (i.e. regulating their practice through, for example, legislation) as threatening their key ability to operate outside of the medical system, much like some midwives have long argued.
In my research, I indeed saw how the imposition of a protocol affects the emotional labour of midwives during birth. New mothers sometimes complained to me that despite the midwives’ promise of providing care ‘from the heart’, the latter often reverted to a ‘care by numbers’ approach, especially if a hospital transfer loomed due to a complication. Following Annemarie Mol, Ingunn Moser, and Jeanette Pols in their argument that care and control are not necessarily opposites, I hold that in such cases taking control and making tough decisions are crucial elements of practicing care, especially during the high stakes and volatile process of birth. In my research I thereby highlight the way in which the emotional and medical aspects of care are constantly negotiated within the practices of both those who care and those who are being cared for.
Boundary Work in Practice
As the debate in the Netherlands took shape through opinions voiced in newspapers, on the radio, and on social media, the perspectives of midwives, obstetricians, and doulas were presented. However, as many indignant Dutch doulas highlighted, the voice of the person giving birth was almost completely neglected. Looking at why pregnant women are choosing to hire doulas in the first place is indeed a necessary starting point to understand the care gap that doulas are filling.
While some midwives would like to see doulas disappear, their current popularity seems to suggest that they are here to stay. This means that midwives have to find a way to delineate their role from that of the doula. As my research in Indonesia has shown, studying how these boundaries are made in practice can reveal how claims about the emotional and the medical can become entangled in a politics of care, which can have profound effects on care practices and the experiences women have of their births. The Dutch debate on doulas further illustrates the extent to which emotional labour is implicated in biomedical care – as becomes clear from the problems that arise when the emotional aspect of care is decoupled from biomedicine and taken over by doulas. Therefore, I see the advent of the doula and the heated debates on the role of the midwife as providing a unique opportunity to ethnographically examine the role of the emotions in biomedicine.