Monday, July 04, 2005

About those postpartum visits...

By far the piece of my doula practice that I feel least comfortable about is my postnatal visits.

My standard package of services includes a minimum of 2 prenatal and 2 postnatal visits in addition to providing support throughout labor and delivery. The prenatal visits are easy. I take a history on the mother, find out her hopes for the birth, learn what she and her partner expect of a doula, discuss postpartum support plans, etc. etc. Usually these visits run over an hour, sometimes they approach two hours. I have scheduled third meetings with some clients to give us more time to cover everything from breastfeeding to relaxation.

The birth pretty much takes care of itself. What to do is obvious.

But then the baby is born and everything changes -- at least for me. I no longer feel part of "the team." I see a new family and recognize that they need an insulated space in which to integrate their birth experience and their new child(ren) into their previous lives. I see new parents who have not slept in a day or two or three and who just need to curl up together in a big bed with the baby and not get up for a week.

On the one hand, the need for a doula is never higher than in this critical postnatal period. The doula can help insulate the family, provide food and other needs so the family can cocoon, offer assistance or reassurance that recover and breastfeeding are proceeding, and encourage the mother to rest and limit visitors.

On the other hand, much of this happens only if the doula takes a leading role in the post birth periord. I am not that kind of person. I always think "This is not my show" and am reluctant to interfere or be overbearing.

Add to my reservation the sudden influx of family, many of whom look at me as if I've wandered off the street into their daughter's delivery room, and I lose all gumption to assert myself. Moreover, when I know a lot of family and friends are visiting the new parents at home, I don't want to further limit the family's private time by adding my visit to their list.

My own experience with the postpartum period was that I pretty much wanted to be left alone. I had my husband to take care of me. I didn't want to see anyone else. In deference to that, I try to leave it in the mother's court to dictate when and whether she'd like me to see her.

But often, despite my phone calls and e-mails, mothers have problems and do not call on me. When I saw one mother six weeks postpartum, said "oh, that's right -- I didn't tell you I got a uterine infection at 3 weeks and had to go back into the hospital." Another told me when I called 5 days postpartum that she'd been having a horrible time feeding for the past two days and was at her wits end.

I hear these things and reprimand myself that if I'd worked harder to cultivate a bond with these women they might have called on me. Or I second guess the intervals between my contacts to them; should I have called every day?

In the end it's a balancing act. The new parents' fatigue, privacy and bonding time often stand in opposition to services I can offer that I believe would help.

Ultimately I defer to the family but keep myself -- perhaps annoyingly so -- within easy reach. I visit or call every 2-3 days in the first two weeks. I always ask if there's anything I can do. If they no, I suggest a few things they might not have thought of (grocery shopping? walk the dog?). If they still say no, I urge them to keep a list for the next day of things I might do to help.

Still, short of moving in, I have to recognize that I can't "make it better." There is a certain hardship that comes with new parenthood. It is unavoidable and it is part of the rite of passage. I can't be at every feeding. I can't help them dodge middle of the night feedings. I can't take away the alternating feelings of elation and shock that accompany the suddent and complete responsibility for a helpless new life.

The best I can do is be ready at the fringe and come in when asked. And make sure they know I'm there if they aren't asking.

As I'm sure is apparent from this rambling post, I have guilty feelings about my clients who delivered two weeks ago, and whose home I have only visited on two separate half-hour occasions since birth. They are having a tough go and I'd love to do more. But every time I call, they decline my offers. I jokingly remind them that they've paid for this as part of their fee and that I am happy to clean bathrooms or bring food.

Then I think of myself in the same position seven years ago and remember that as much as I wanted the six weeks of massages, baths and family-prepared food that is part of Indian culture's postpartum period, I was determined to get through my babymoon on my own. I took pride in that. I have to honor that desire in others, much as I wish it was moderated.


Blogger Dynamic Doula said...

What a relief to know that I'm not the only doula who feels awkward in the postpartum period! Mine is a little different (and something I feel guilty about)- I just emotionally detach after that baby comes out. I don't know what that's all about but if I could skip a postpartum visit all together and just have the postpartum doula seamlessly come in and take over, that would be my first choice. It's unnerving to me, it bothers me a lot- and I am constantly assessing *why* I do this work, having these responses... There is a big emotional difference from the needs the client has of you (as the doula) before/during the birth, from what they need after. I have also had clients not call me after returnign to the hospital again, having the baby come out sick, etc. I don't find out till weeks later, when the crisis is over (or integrated, at least)! I always have to go over- do they not trust me? Is it something I said? Am I too overbearing? etc. when things like that happen because I can't think of a good reason why they wouldn't call!

In my contract now I let my clients know that I remain on call (24/7) for them up to 48 hours after the birth- my first client's baby had to go to the nursery after I left and they called me back that night to sit w/the baby so mom could sleep - she couldn't rest knowing her baby was in there alone. So I 'baby sat' for five hours! Ever since that birth I realized that things happen in the first couple of days and that couples need to know that they dont have to wait until office hours to get some help from someone they trust. It has been well received by my clients (but never used! @#!%). LOL

Oh, the joys... ;)

5:21 PM  
Blogger Linda said...

I'm so glad you and Dynamic Doula are talking about this. In birth circles it seems these issues are so rarely talked about.

It's like... there is this fantasy, this mythology, of what birth is about that is often not the reality that women experience, and the reality is not represented in the literature nor even in the stories that women tell each other. (I think I am beginning to understand why this might be, but it is such a new concept to me too that I don't yet have the words to explain.)

The fantasy is that professionals facilitate the path to Birth (with a capital 'B'.) Either that or that they are irrelevant. So there is supposedly either a positive effect or no effect, but not a negative one unless they are just "bad" care providers. But speaking in general of holistic or women-centered care, the effect is regarded as only either positive or absent, because the intention is good and because there is this idea (the fantasy) that birth just IS best served by doulas and midwives.

I didn't want anyone around either after my first birth -- I could have used help, certainly, I was physically in bad shape, I was exhausted and depressed and had not bonded with the baby. In addition I had a terrible time breastfeeding. When the midwife came for the three-day and three-week check-ups, I revealed none of this. I desperately wanted some support, some help, some companionship, and actually felt abandoned by the midwife. Yet I felt uncomfortable around her when she did visit and didn't want her ministering to me.

I think the problem is in birth being such an intrinsically *intimate* thing, and of those who are available to help (at least in our culture,) there is not a genuinely intimate relationship, but rather mainly (although well-intentioned and from a place of caring a love) a superficial and mostly contrived one.

I knew I was *supposed* to feel love and sisterhood and all that. I wanted it, too. But when we went through the motions, it felt deeply wrong. Which added to the depression, but also made me want to isolate myself more in order to protect myself from that "wrongness".

I don't think I was/am alone in feeling these things, I think it's fairly common but that it's not consciously recognized or acknowledged, women can't put a name to it so they can't talk about it. Or they don't allow themselves to be aware of it because it's not considered "normal", not what the fantasy dictates. I know that was true for me -- I didn't want people thinking I was a freak that I couldn't feel what I was "supposed" to feel about the American way of birth.

I don't know what the answer is in our culture. Professional doulas and midwives are much preferable to the more common options, but maybe we need to begin to admit and accept they they aren't always ideal either; perhaps they are more than anything a band-aid to the problem of institutionalized and/or managed birth and all the conditioned neuroses surrounding birth and the lost wisdom that was once just part of who we are as women.

9:09 PM  
Blogger Dynamic Doula said...

Oh Linda, I so agree with you on so many points! I've noticed that the intimacy that is created in the labor room is so different from what I experience with my clients at the post partum visit. I see these women sweating, groaning, I hold their partners while they are worried, I answer every question, and I sweat and groan along with them... and the space really does hold all that within it. And then we leave the space and it's back to our need for personal space, there is no physical comfort anymore, it's almost like the cord was cut when I left the birth room, if that makes sense?

We live under this ridiculous social expectation that we should be able to go home and tackle motherhood and be okay- and I think we're finding out more and more that it is just not the case.

What I have seen with my clients is that they are primal for that little while during hte birth, and as soon as the baby is born they SNAP right back into their heads (values/boundaries/expectations/comfort levels etc)- and it sort of closes the valve on the intimacy we'd just created. I think that's a lot of the reason why help is refused after birth, I always have this feeling that my client is waiting for me to finish the post partum visit so they can get back to focusing on the next task at hand, rather than seeing my presence as an opportunity or a doorway to other assistance.

Interesting discussion. :)

11:14 AM  
Anonymous Melissa said...

I'm postpartum now, and I have a different perspective this time around than last. With my first baby, I had a doula (along with a midwife) who did not do any pp visits except for the 6-week pp visit. I would have loved for her to check in every few days or so, but she never did. By the time she got here at 6 weeks, we had a very distant, almost formal sit-down, and I told her everything was great even though I was really going through some heavy emotional/adjustment stuff that later turned into depression. I didn't hire her a second time. ... It's 4 weeks pp right now and we just got the company/helpers out of our house. We did need them desperately because my 2-year-old has been like a different kid (wild, 'energetic' doesn't quite cut it) since the new baby got here. They were lifesavers, but it was tough on me because I really had the need to be alone and deal with things unobserved this time around. I still really looked forward to my midwife's visit days, though, because I associated her with the birth. Though she has urged me to call her about any little thing, I haven't. I don't know - I guess I do feel like I should be handling this stuff on my own.

1:45 PM  
Blogger doulicia said...

What a great bunch of comments. Dynamic Doula, I really like your idea of calling the first 48 hours post-birth "on call." Though I also cherish the post-birth recovery time, so running right back for a PP visit would be tough.

And Linda, how right you are that this is a societal problem. Doulas are largely a substitute for wisened family members who would/could accompany mothers on their birth and recovery journies. I love reading "old" accounts of birth where female family and friends essentially moved into the house for a weeks to help with the birth and the postpartum period. Kids were sent to other houses so the mother could have quiet...women made meals round the clock and covered cleaning and household chores. Yes, the expectation was that you'd do the same for them. But wouldn't we today do the same?

And Melissa -- congratulations on your new baby. But you capture exactly the tension I think exists with doulas and clients. Doulas want to help and mothers would appreciate some help. But doulas respect mothers' desire to "tough it out" or their assurances that "all's well" and mothers feel obliged to put up a front.

Wouldn't it be different if you weren't given any choice and someone was just sent to your home -- like a visising nurse -- daily for the first 2 weeks for at least 2 hours a day? If you knew it was what was expected, I think you (I know I would) look forward to those visits.

2:11 PM  
Blogger Linda said...

When my first was born my mom did come to help out, but it was a disaster. First, although I love her very much, we are very different people and I don't feel particularly close to her, not in an intimate way anyway. Second, she was not able to enter into the "birth bubble" with me. She understands the specialness of a new baby, but has no idea about the spirituality of birth and postpartum for the mother, I think at least partly because she wasn't allowed to experience it herself.

I think this is one reason unassisted birth has become a "movement" (albeit a small and fringe one) in our culture -- because in our culture we are all so isolated from one other psychically and spiritually. I think that having a virtual stranger be intimately involved with the birth and postpartum is going to feel essentially wrong in any culture, but in more traditional cultures perhaps women have generally had deep, comfortable, secure, nurturing relationships with other women so that it was appropriate to have others around in birth. Not so in ours. But we still are expected to cater to tradition that is no longer relevant to the way we exist in society, the kind of relationships we have with others.

Having said that, I have to wonder how much it is actually true that in "old" times women generally did have relationships with their neighbors and family that were intimate enough that their presence at birth was appropriate and not an intrusion. What we know of the sociology of birth tells us that there have "always" been midwives -- at least as far as we know, that is, in recorded history. But of course humankind reaches much, much farther back than that, and we have no way of knowing what more matriarchal or less agressive societies were generally like, in terms of how they treated birth and postpartum. As Michel Odent has observed, recorded history gives us accounts of primarily partriarchal aggressive societies, and he hypothesizes that in such societies there is an advantage to disturbing the birth process and postpartum in some way, for it serves and perpetuates that system. (See "The Scientification of Love.")

As to your question, "Wouldn't it be different if you weren't given any choice and someone was just sent to your home -- like a visising nurse -- daily for the first 2 weeks for at least 2 hours a day? If you knew it was what was expected, I think you (I know I would) look forward to those visits."

I can say with all honesty that I would find it an intrusion and an annoyance, and potentially harmful (say, if the nurse happened to have different ideas than me about how I should be doing things and felt duty-bound to report me to the authorities.) But then I'm not one who just wants to do it all myself out of pride -- I really just do not want people around unless they are doing non-intrusive practical things, or are *in* it with me.

A couple of examples: 1) a neighbor, an acquaintance really, who brought a fully prepared dinner, set it up for us, and then left. She didn't expect me to socialize with her at all. It was such a relief and such a kindess. And 2) when a dear friend of mine who is deeply involved with birth issues and genuinely in love with babyhood, came to visit when I was feeling down, and brought nurturing gifts and raved at length about how beautiful and charming my baby was.

I think the reason why these visits both worked was that they did not attempt to be anything other than what they genuinely were, and they were aware (empathetic) of my actual needs. I think that we get caught up in what we "should" be doing for the mother -- which amounts to a role in a play -- rather than what is naturally indicated and authentic. And the mother, in her highly open and vulnerable state, *knows* how authentic it is or is not, and this affects her deeply. She can even predict it, and so may try to avoid it by declining help (that, in itself, she really would appreciate.)

2:01 PM  
Blogger I am a Milliner's Dream, a woman of many "hats"... said...

I have remained "on call" for those first 48 hours for clients now, for 14 years as a doula. I have had clients who run the entire spectrum from very needy to entirely independent immediately postpartum.

For some I receive phone calls, visit, even stay over in their home. I have supported clients with special needs--like a baby re-admitted days after discharge with jaundice, etc.

For others, it is very difficult to even schedule the regular postpartum visits I usually do--anytime in the 8 weeks postpartum, because they are either a.) determined to 'do it on their own' or they are so confident they don't need help--and want that private babymoon.

I have always felt strongly that I learn from every birth and postpartum experience with clients. I take something from each birth into the next.

What I have come to realize in the last year or so is that my knowledge of postpartum, which really felt--um...sufficient, is the same. I learn from every client, I learn from every birth and the woman's postpartum experience.

However, I know now in the last six months that my craving for more knowledge of postpartum and adding to my 'toolbox' is truly growing.

I can never know enough and I am excited to find ways--within the limits of time and budget--to strengthen my knowledge base of breastfeeding, postpartum depression and other postpartum issues.

Call it a paradigm shift, a lightbulb moment or a realization of my limitations...but I find it absolutely critical that I become better prepared and more ready to answer clients questions, address their specific needs and concerns and to be an ever more present resource to them postpartum.

12:45 PM  

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