What would you do if you found out that your own biases and beliefs about birth were disempowering the clients you are serving? Chances are you started your important work as a doula after your own birthing experiences. And maybe that experience was a powerful, amazing birth that you believe all pregnant people deserve. More likely though, it was a birth that didn’t go as planned and you might even feel you need to protect your clients from their providers and the birthing system as a whole. 

What if I told you that - positive or negative - your birth and beliefs about birth are deeply impacting your clients. Especially if those beliefs and experiences have not been examined. By understanding what biases are and how to take inventory of the ones you hold onto, you can truly empower yourself and your clients rather than creating an unintended dependency on you for their birthing experience and decisions. 

What are biases?
So what is bias and why does it matter?

A bias is an inclination and preference toward one type of person, choice, or thing over another. Biases are not inherently negative but are always a powerful force behind our behavior. To reserve your conscious thoughts for more complex problem solving, your brain creates shortcuts for categorizing and making sense of the constant input of information coming in through the five senses. These shortcuts can then develop into biases. 

Knowing that biases are an evolutionary development that can help take some of the shame and drama away when we start to identify and address the biases we hold. This process is happening mostly in the background, outside of our conscious awareness. Biases have a very real impact on our lives and those around us, but getting lost in a shame spiral about it isn’t necessary or productive to positive change. 

Two Types of Bias
Your mission is to support birthing people in whatever choices they make around their birth. Why is it then that when your client says they are considering an elective induction you can feel a rush of adrenaline and an overwhelming sense of dread. You leap into action and start listing off all of the potential risks and the cascade of interventions you feel are sure to follow an induction? Is this not in direct conflict with your mission to support your clients in what THEY want?

So what’s happening here?

This is likely a case of implicit bias creeping to the surface. According to the National Center for Cultural Competence, an implicit bias “operates outside of the person’s awareness and can be in direct contradiction to a person’s espoused beliefs and values;” whereas, a person with an explicit bias “is very clear about his or her feelings and attitudes, and related behaviors are conducted with intent.”

Common explicit biases in the birth world are providers in the medical model being staunchly opposed to home birth or VBACs. Although explicit biases are damaging, they are at least often out in the open and therefore easier for birthing people to avoid and navigate. 

Implicit biases are more dangerous because of their hidden nature. This would look like an OB that says they are VBAC friendly, but then they start pressuring the birthing person to have a repeat cesarean because that is what they are comfortable with

Birth work is intersectional. It is the meeting places of so many important experiences, social issues, and identifiers. Essentially becoming a perfect situation for biases to be formed and show up for everyone involved. This is why it is critical to do the internal work necessary to identify and address your biases as a doula. There are too many opportunities for shortcuts to evolve and derail the goals and needs of your client. 
Addressing Biases
Imagine you and your client work together to prep for their next prenatal visit with their OB by building a birth plan, role-playing, and getting educated on each of the client’s birth preferences. You are confident that your client is fully equipped to communicate their goals and stand their ground if there is any push back from their provider. Only to find out that the OB suggested something completely different than the original plan, and your client is feeling conflicted. 

Now consider these two possible responses:

1. You gather all of the evidence based articles you can find, put together a list of patient rights, and remind your client they can always change providers. You even have a list of alternative options for them to review just in case the provider didn’t explain them. Then you send them the B.R.A.I.N. exercise to make sure they fully understand the option they are considering. 
2. You know that you adequately prepared your client for this meeting and you fully trust in and support their autonomy. Because they do seem a bit conflicted, you take time to genuinely ask them how THEY FEEL about the proposed procedure or change to their birth plan. You listen to their answer, help them address any underlying fears or concerns, offer additional resources if they are interested, and then you truly support whatever choice they make.
   
   
   

How does each of these responses make you feel?

Option one is based on fear and likely an implicit bias about some specific procedure, birth setting, provider, etc. And it DOES NOT empower the client. It centers you and your belief that they must be saved from this particular choice. It creates a dependency on you to make the right decision for your client. 

Option two comes from someone who has done the work to address their own biases. It holds space for the birthing person to honestly express their thoughts and feelings, without the added pressure of a doula determined to save them from themselves. This response doesn’t deny your own beliefs, knowledge, or experiences - it just doesn’t make them the star of the show. 

So how do you get to a point where option two is your natural response? You must start confronting your implicit biases. This is not an easy process and will not happen overnight. It is a journey that requires honesty, commitment, and accountability. But it is essential if you are planning on serving birthing people in a positive and impactful way.

• A great place to start is by taking Harvard University's Implicit Association Test (IAT). This will help you identify important biases you hold subconsciously
• Next is fostering awareness around those biases in your daily life. This might look like:
  • Recognizing when you had a stereotyping thought about someone, something, or a group of people
  • Questioning that thought - is it even true? What are some examples of times it isn’t true
  • Reframing the thought into something positive rather than negative
  • Empathizing with the person/group you’ve stereotyped - how would it feel if automatic assumptions were made about you?
  • Actively seeking out opportunities to engage with the people, places, and things you have biases against. Find ways to learn more and put yourself in contact with things that you have discomfort with to break down your biases and negative assumptions.
• Alongside awareness is the need for reflection and accountability.
  • Journal about the times you’ve recognized these biases and stereotypes creeping into your thoughts
  • Share these instances with a mentor or safe person that is also engaged in the hard work of addressing biases
• Repeat. This work is never done. Make sure you have a plan to stay engaged with this process. It is easy to get distracted, especially if you are in a place of privilege (race, economic status, gender, education, etc.). Get an accountability partner. Schedule time to reflect. Do whatever you need to do to keep pushing forward. 

Birth work is not about you. Or me. It is about birthing people. It is about constantly recentering them as the authority on their bodies, their babies, and their experiences. Understanding what biases are, why they are so important, and how you can start the work of confronting your own you are on the path to being the best doula you can be. 

This stuff is hard work and requires you to take a deep and honest inventory of yourself. This is part of the reason I created The Advanced Doula Workshop. So many of my fellow doulas received plenty of training on comfort measures, the stages of labor, and what to pack in their doula bag, but there is little space for this kind of intense self-exploration. 

Join my newsletter to stay up to date on the next Advanced Doula Workshop and learn more about how to tackle your biases to make a positive impact on your clients and the birthing world as a whole. 

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How many times have you heard -- or even said yourself --  “just switch providers,” after someone has a difficult prenatal appointment?

This response makes a lot of sense on the surface when your client is clearly mismatched with their provider, their goals and choices are not being supported, or they are not being treated respectfully. You know that if a pregnant person is meeting resistance around their preferences in their prenatal appointments, it is likely going to continue into the birthing space. You want to protect them and do everything possible to help your clients have empowering, beautiful, and safe birthing experiences. 

So why not just switch providers if they aren’t on board with your client’s preferences and birthing goals?

The short answer is that this doesn’t address the core issues here. And it absolutely doesn’t guarantee a better outcome or experience in the birthing space. 

We need to dig a little deeper. Let’s look into common reasons for provider-patient mismatches and the impacts of privilege and barriers to care, first. Then we can review practical skills and tools to support your clients in advocating for themselves at ALL times -- especially when switching providers just isn’t a realistic (or even the best) option. 

Common reasons for provider-patient mismatch
How do you know there is a serious mismatch between your client and their provider in the first place?

When our clients come back from a prenatal appointment feeling dis-empowered, unheard, or disrespected, it is easy to jump into protective mode. But this is precisely where we need to slow down and uncover the core issue before we can offer impactful support. 

Understanding common themes and barriers to communication will help you support your client in finding ways to meet their goals without immediately suggesting they jump ship. 

Communication barriers and breakdowns are almost always the culprit. And this can take many different forms: 

• Is the client informed enough about their options and goals to ask the right questions? 
• Is there a fear of authority preventing them from speaking up? 
• Are they feeling confident and supported when they walk into their appointments? 
• Do they have team-building skills or is there someone with them who does?
• Is there a power differential at play between them and the provider?
• Are there biases -- both with the provider or the client -- that may be blocking effective conversations?

Attending at least one prenatal appointment with your client can give you the opportunity to create better communication and work to build a sense of trust for the client and the provider. Having everyone rallied together around a common (and clearly communicated) goal can make a major difference in how your client feels about their care. 
Privilege and barriers to care
Are you taking into consideration privilege and barriers to care before suggesting your client find a different provider? This can make a huge difference between your client stepping into (and keeping) their power and feeling unheard, unseen, and disempowered. 

The reality for many birthing people in the United States is that they have very few choices or options when it comes to who actually provides care to them during pregnancy and birth. And if you fail to address these realities you cannot get to the core of the disconnect or fully support your client in having a positive birthing experience.

They may live in a state with legal and logistical barriers to midwifery care or community care options… 

Or in a rural area with only a handful of providers… 

Or they may be heavily restricted by their insurance coverage… 

Even if a client switches providers, what happens if that provider is part of a large group and they aren’t on call when your client goes into labor? What happens when your client plans on an out-of-hospital birth but they end up needing to be transferred?

What about the crisis level racial disparities that black birthing people face every day in our country? Will switching providers guarantee that every nurse/doctor/midwife they encounter will not have implicit or explicit biases against them, simply because they are birthing while black?

You must address privilege and biases in yourself first, and then acknowledge this reality for your clients if you are committed to changing birth for individuals and for society as a whole. 

Your job is to help identify where these barriers exist and help your client change the way they think about their care, their role in the relationship with their provider, and help them develop skills to advocate for themselves no matter what happens during their pregnancy and birth. 

What to do instead of suggesting someone switch providers
So what do you do when your client comes to you feeling defeated, overwhelmed, and dis-empowered after an interaction with their provider -- instead of suggesting they pack up and move onto greener pastures?

You go back to the basics of doula care. You hold space for them. And you provide them with a new way of thinking about their power in all experiences, not just in birth. 

Your suggestions and opinions might be helpful, but do they help your clients step into and keep their power? Or are you creating a dynamic where they turn to you for strength and guidance rather than turning inwards to tap into their power and wisdom?

Here are a few concrete steps you can take instead of telling your client to fire their provider:

• First, validate how they are feeling and what they experienced.
• Then, ask questions that help them get to the core of the disconnect. Is there a bias that needs to be dealt with or a breakdown in communication you can help them identify?
• Next, educate them on their options without trying to influence their decision. Help them get crystal clear on their goals, role play effective communication, and come up with a plan that recenters them as the expert on their bodies and their care. 
• Finally, offer to go with them and be a supportive presence at their next appointment.

Outside of these suggestions, it is so important to do the internal work on yourself required to be an effective advocate. Deal with your biases. Get additional training around communication and advocacy. Keep learning and growing as a person and a professional. 

If you don’t understand your own power you cannot help your clients see their strength either. 

The grass is rarely as green on the other side as we hope it will be… especially if the core problem isn’t dealt with from the beginning. 

The ultimate goal is to help clients discover their power and develop trust in themselves. Rather than creating dependency or ignoring your client’s power -- by quoting stats of different providers or simply handing them a list of providers that you prefer -- help them discover true empowerment by getting down to the bottom of their belief systems and the core of what they want to do. 
Recognizing what is causing the disconnect and understanding what barriers your client might be facing in access to their care will help you develop a solid foundation for your client to connect with and keep their power in all of their interactions -- before, during and after birth. 

Your work is incredibly important. You have the unique opportunity and are in a position to change not only your client’s pregnancy and birthing experience, but to change the way they move through the world. And to help them believe in and trust themselves. To transition into parenthood with confidence and power. 

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Good communication with your care team during pregnancy is an important start to building the foundation for your birthing goals, but you may be blindsided by a comment you don’t know how to handle. Maybe it’s not an extremely negative comment, but it still hurts none the less. Language matters. Words are strong. If your provider says any of these, it may be a red flag:

So I heard a story recently that has my brain reeling. 

During a birth, comments from a care provider about the baby "blowing out" mom's vagina to then give her the option of forceps or cesarean  after only 30 mins of pushing and baby doing well. 

As a doula, one of the very first questions I ask my clients is what is their belief system around birth? What are their birth experiences? What do they know about their own birth? I want to understand their perception of birth in their birth culture.

What the majority of families describe is a hands-off, family-centered, low intervention, natural feeling of care. They talk about wanting to be seen as a normal person who’s having a baby and not a medical condition. ​