Doulas, Midwives, and Birthing Beads

“If a doula were a drug, it would be unethical not to use it.” John Kennell, MD

The photograph above is of a strand of birthing beads. In fact, these are my personal birthing beads. Birthing Beads is a practice I was introduced by my mentor, Jeannine Parvati Baker. Jeannine, half Shoshone by birth (her grandfather was full-blood, her grandmother Jewish from Eastern Europe), and grew up steeped in ritual, ceremony, and tradition. She invented or re-invented many of the ‘alternative’ birthing rituals that have now become so popular that one might think they’ve always been part of the alternative birthing culture. Her belief in the sacredness of birth as a rite of initiation for women, the power of women to birth, and the primal importance of restoring birth to its sacred place in life was central to her work.

She wrote the first modern book on prenatal yoga (it was my copy of Prenatal Yoga and Natural Birth that I purchased in 1981 at the Cambridge Food Coop, when I was 15, that first led me to her); she was the first to use the term conscious conception (also the title of a book she wrote), and wrote Hygieia: A Woman’s Herbal,  the first modern women’s herbal which connected botanicals to female archetypes. She also brought us the modern version of the Blessingway.

Jeannine passed away in 2005 as a result of Hepatitis C, contracted from the Rhogam she’d accepted after the birth of her twins, and before Hep C was tested for in this blood product (Jeannine was amongst thousands of women who died due to infected Rhogam. It is now tested for Hep C, HIV and other blood-borne diseases).

But long prior, in 1988, Jeannine welcomed me into her life’s work and her small cabin in rural Utah, with formal initiation into her practice of women’s wisdom traditions, the spirit of many which I have maintained in my life and practice, even today.

Beads, Births, and Mother Blessings

I had begun to study with JP at a distance in 1986. It was around this time that I first brought birthing beads into my midwifery practice. As a client got close to her due date, I’d leave my strand of beads with her. The intention was that the strand of beads would serve as a reminder of the power of the larger world of birthing women, a strength she could draw on should she be inspired or feel the need. After the birth she’d add her own bead, return the strand to me, and it would be passed on to the next woman. So the strand – and its meaningfulness – would grow.

As the years went on, rather than leaving my own birthing beads with clients, I began to encourage women to create their own birthing bead strand that they could keep or share with women in their own circles. To wit, I asked each woman who was coming to her Mother Blessing Ceremony*, which I led for many of the mamas in my practice, to bring a bead to place on the birthing altar, and during the ceremony we’d add our bead to the strand, with a special wish, prayer, or blessing for mom and baby.

It was a symbolic gesture, and one that surely modern medicine would consider irrelevant toward any contribution to the birth outcome. But was it merely a gesture without impact? Studies – both anthropologic and medical – have shown that ritual, belief, and ceremony can have tremendous power to heal (and conversely, ritual can harm, if that’s the intention and belief behind it, a phenomenon called the ‘the nocebo effect’ and also well studied.). Studies have also shown that the power of women supporting each other in labor has a significant, important, and beneficial impact on women’s experience of birth, as well as birth outcome, a topic that needs critical attention today as much as ever – if not more.

Are We Really a Cut Above the Rest?

We are experiencing a national birth crisis. While we’ve been fed a myth that all of our technology has made birth safer for women and babies, the sad reality is that this is just not true, at least the way it’s applied currently in the US. In fact, the only way in which we are a ‘cut above the rest’ is in our cesarean rate, which, at a 34% national cesarean section average rate, is one of the highest in the western world, and is far above the rate deemed acceptable by the World Health Organization for maternal and infant safety. Cesarean section actually increases a woman’s chance of infection, hemorrhage, other complications, and even death by as much as 30%, a frightening statistic Neel Shah, MD, an OB-GYN dedicated to reducing this rate. Neel’s article published in the Washington Post titled “I'm an OB-GYN. I'm Not Sure Every Baby Needs to Be Born in the Hospital”, is a good read.

The US is also one of only two westernized nations to have an increasing maternal mortality rate. A recent study published in Obstetrics and Gynecology found that the maternal mortality rate in the United States increased by more than 25% from 2000 to 2014. Further, natural birth itself appears to be going extinct. Not long ago, a team trying to study the natural length of the stages of labor in order to assess the validity of Friedman’s curve, a tool in use since the 1950s and considered partly responsible for overuse of induction and cesarean section, was unable to locate any one hospital setting in which enough women were giving birth naturally – to the point that they concluded that natural birth was indeed, rare, en masse.

One strategy that has been found to dramatically lower birth intervention rates and improve the experience and outcomes of mothers and babies, even in a hospital setting, that midwives have long known and which doulas also now also provide, is the continuous support of a woman as a birth companion during labor.



Women Supporting Birthing Women

It’s said that it takes a village to raise a child, and it is so true that the support of community can make this most daunting task a little less overwhelming. I also believe that the village concept applies profoundly to women’s experience of birth. The presence of women helps us to birth in the most natural, physiologic way.

This is not a new idea. Women have gathered to support women in birth from the beginning of time, and even in those rare few cultures where women go off to birth alone, they do so from the context of a supportive community of women who have prepared them for birth as an experience that requires them to go deep within and find their power and resources, and who will embrace them on their return, with rituals that encourage rest, and nourish the mother’s body with restorative foods and herbal tonics, heat, and massage. In most cultures, though, women are present for each other in the form of midwives and women relatives at birth.

At least 11 randomized control trials, in a study done over 20 years ago, showed that support by a doula, student midwife or midwife, who provides continuous support consisting of praise, encouragement, reassurance, comfort measures, physical contact and explanations about progress during labor, positively affects obstetrical and neonatal outcomes. Labor is shorter, birth is easier with fewer interventions including epidural anesthesia, forceps, and cesarean section, the mother has a more positive association with her birth experience, and breastfeeding is more likely to go smoothly and successfully, and she is less likely to experience postpartum depression.  Depending on which study you look at, doulas have been shown to reduce cesareans by anywhere from 28 to 56% for full-term births.

Midwifery care is similarly associated with a statistically lower rate of birth interventions, and thus maternal safety, as well as a greater sense of satisfaction and empowerment for women with their birth experience.

Why does “women-helping-women” facilitate birth? The involvement of doulas and midwives in prenatal care can help moms to stay healthy, and during labor, techniques such as massage, encouraging women to stay active with walking and dance, providing light, nourishing foods that keep mom energized, all seem to have a positive impact.

There’s also something else – something less tangible – but nonetheless very real: Having another woman present, there for our comfort and connection, encouragement and empathetic care, has been shown to improve the likelihood of a natural birth, even if she’s not trained as a midwife or doula. This was first demonstrated in studies of birthing women in Guatemala who had women labor companions in the 1960s and 1970s, and became the prelude to The Doula Study by Dr. John Kennell, a leading researcher and advocate of mother-baby bonding. Having another woman present, it was found, particularly another woman who has some training in how to support women in labor, can help us to feel safer. A feeling of emotional and cognitive safety encourages healthier birthing on a physical, hormonal level.

A feeling of safety is key: It’s foundational to the evolutionary biology that has allowed most mammalian species to survive. Fear increases production of the stress hormones adrenaline and cortisol, which in turn, inhibit labor by halting uterine contractions. It’s what keeps a mother giraffe from pushing her baby out when she senses a pride of lions nearby, and it’s what can cause our own labors to stall, sputter, or not even begin in the first place, increasing our likelihood of induction, augmentation with Pitocin, and a cesarean section. In female animals, even if she’s in active labor, fear can shut the whole thing down until she gets somewhere safe, at which time the process can resume. A recent study of over 2000 women in Norway confirmed that fear alone could add, on average, 47 minutes to the length of labor. Longer labor increases a woman’s likelihood of an epidural, labor augmentation, and cesarean or other operative intervention. This might not sound like much time – unless you’re in labor – in which case it can feel like an eternity. And importantly, a longer labor often means higher risk of intervention.

For animals, a safe environment facilitates birth, and danger – perceived or actual – inhibits labor. For human women, support during labor enhances healthy labor physiology by improving the natural release of oxytocin, improving the quality of uterine contractions, and imparting to  mothers feelings of control and competence.

Unfortunately, modern obstetric care creates an environment in which women are subjected to frequent intrusions, invasive institutional routines, unfamiliar personnel, lack of privacy, and other conditions that may be experienced as threatening on a conscious or instinctive level.

Much as we’d like to think ourselves above the animal world, on a physiologic level we’re all still very much driven by instinct, fear, safety, and hormones! Companionship in labor, when it is taking place even in the potentially “stressful, threatening and disempowering clinical birth environment” has been shown to reduce reliance on medical interventions and “may to some extent buffer such stressors.”

Now I’m not saying that every woman who experiences a halt in her labor or requires induction does so because of fear – there are numerous factors that influence the birth process. I am absolutely not laying blame on any women for her birth outcome. Further, as a midwife and MD trained in obstetrics, I’m grateful for interventions when we need them. However, I am saying that it’s been over three decades that our rates of intervention in birth have been recognized as dangerously high, that the statistics are getting worse, not better, and that if having supportive women present can help facilitate a healthy birth process, we should be doing everything we can to encourage this – including full coverage for doulas for every woman birthing in a hospital or birthing center, and access to midwives for all women who want this option. A woman’s beliefs and attitudes about birth are shaped by her culture, and contribute to her birth experience and outcome. The need for a change in the birth culture in this country has become critical for women’s well-being, and of course, that in turn means for the well-being of her baby and family.

Circling Back to the Birthing Beads

A string of beads is not a substitute for a midwife, doula, or loving female birth companion. It’s not going to solve our modern obstetrics crisis. It’s not going to create funding so that all women have access to doula or midwifery care. And it’s not by itself, going to lower the cesarean section rate. It’s also not a panacea any more than having a midwife or doula can guarantee a natural birth. Women will, at times, need birth interventions regardless of the best support, best preparation, and healthiest attitude. But choosing to have a supportive birth companion, and bringing in ritual that affirms the inherent ability to birth most of us have, is an important step toward changing the birthing culture for women. Birthing beads, to me, are a reminder of that important woman-support as we journey into the unknown of labor and birth.

Of course, having a baby is a big deal and a big unknown – it’s absolutely normal to have some fears during pregnancy and labor. Maya Angelou once said in an interview, that when she had something difficult to do, something she was afraid to do, she called on the spirits of all those who have loved her – living or passed on – and said to them, I need you now, so come on this journey with me. Birthing beads are a way to call on the strength and love of all of the women who have come before us, and those who love us, to be with us when we need them. Perhaps it’s a tradition you’d like to bring into your family, circle of friends, or your community.

Remember – I love hearing from you! Please share your stories of support from other women that helped you in labor, or of birthing rituals that you’ve participated in or brought to your community that are helping to empower women in birth.

(Dedicated to JP Baker and to the midwives and doulas.)

*(I no longer use the term Blessingway out of respect for the Lakota people, whose tradition this is, though I did learn a great deal more about the ceremony during my short stay in Pine Ridge, South Dakota in 1989, from women who shared about it most generously while my husband was documenting the efforts of First Nation food activist, Tom Cook, to bring organic agriculture to “the rez,” for an article for Seeds Magazine).

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As an OB/Gyn, I completely agree with the above. Medical training for OB/Gyn is rigorous and little to no time is spent on natural alternatives to the hospital protocols where we train. I have often said we intervene too much. I like to think of obstetricians as the providers we need when things don't go as planned. Personally, my attending physicians during residency were terrified of bad outcomes because of litigation. What a sad way to spend your life's vocation. I think one remedy would be to change training to either obstetrics OR gynecology, not both. Either way, women encouraging women is key, especially in pregnancy and birth. I love the idea of the birthing beads! Thank you, Aviva, for always being a voice for both the midwifery community and the MD community.


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    Love, really, the idea of separating ob from gyn! As a woman who has given birth 4 times, twice with an ob/gyn in hospitals, once with a midwife in a hospital, and once with a lay midwife at home. The experience with the midwife at home was far and away the best of the 4. Honestly believe women need to wrest the birthing experience away from men. We also need to wrest abortions away from men and medical institutions. Women need to do these things for each other. And not have to rely on old white privileged men in positions of power to grant us permission to do so.