Childbirth is meant to be one of the most special times in a person’s life. It not only signifies the birth of a child but the birth or growth of a family as well. There is now a darker truth coming to light and affecting more families than we may have realized. It doesn’t even seem possible, but it’s true – the United States was just put at the top of the list of the most dangerous places to give birth in the developed world according to a four-year investigation by USA Today. The CDC reports that an average of 700 women die each year in childbirth while another 50,000 women are severely injured. When we look further into the numbers, the statistics are staggering. As maternal mortality rates are declining in other countries, they are steadily rising in the United States.

Two of the top reasons noted in the investigation for maternal deaths include hemorrhage and severe hypertension. These issues require hospitals to keep a close eye on blood loss as well as blood pressure levels. There often isn’t a specific protocol in place to accurately measure blood loss levels and determine when intervention is needed, but rather hospital staff makes an educated guess based on observation. California has implemented safety practices that have cut the death rate in half, however, these standards so far have not been adopted by hospitals in other parts of the country.

Let’s talk about solutions. Can doulas help to ameliorate the situation and bring down these staggering statistics? Very possibly.  In fact, some want to become a doula for this reason. Knowledge is power. However, labor and delivery can be a hectic, complicated time. Doulas offer nonjudgemental, continuous support to the mother before, during and after labor and delivery. Having a doula present as a member of the birth team has statistically shown to reduce requests for an epidural, shorten the length of labor and can significantly reduce the need for a C-section. Beyond their ability to offer emotional support, coping techniques and comfort measures, doulas can also be a conduit between patient and doctor. While a patient is in the midst of the whirlwind of labor and delivery, the doula can convey information about the birth process as labor progresses and remind the patient to ask many of the hard questions they want to be answered, but may not be thinking about as they are busy bringing a child into the world. A research article in July 2017 entitled Continuous Support for Women During Childbirth looked at 26 studies that offered data from more than 15,000 women in 17 different countries from varying circumstances and settings. The review found that women who received continuous labor support, “may be less likely to use pain medications or to have a cesarean birth, and may be more likely to be satisfied and have shorter labors.” (Bohren A, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A, Cochrane Database of Systematic Reviews 2017, Issue 7). It isn’t fully clear what causes hemorrhage, hypertension or other complications of labor, but it begs the question of whether these positive statistics of having a doula could help lower the incidence of those negative effects of labor and delivery.

Finally, the USA Today created a guideline of questions that can be used when speaking with your doctor about labor, delivery, and recovery. Patients can talk to their doula about these guidelines and have the doula ready to advocate for them before, during and after their birth experience. Life should be beautiful. It’s important to inform and empower ourselves in order to protect the people we hold dear. A doula could be an important asset to help new parents achieve that goal.

As a part of the training to become a doula, all of our students go through a module where they learn about different cultural traditions and ceremonies during the perinatal period. Please enjoy this wonderful essay by Halima Sadki on the Islamic traditions of the postpartum period.

Nawal from Egypt

By Halima Sadki

Nawal started her story by saying that in Egypt, pregnancy is almost never a secret within the family. It is known from the first-time mom starts having her morning sickness symptoms. Nausea, vomiting, and fainting are usually the key. One thing Nawal remembers very well is that her cravings were very bad but she said that she was very lucky that she delivered amongst her family and relatives that cooked and provided her with everything she thought of. Her childbirth was very long and unmedicated. As usual, it was attended by the mother in law, her mother, and the Daya (uncertified midwife). The husband is usually very involved in the pregnancy, particularly when the couple lives independently. However, his participation or any other male figure’s participation in the delivery is almost null.

After her delivery, the mother starts a resting period called a “Nifass” (postnatal bleeding). It is about 40 days for most Muslim scholars where the mother is not allowed to have any sex with her husband but she could enjoy everything else. She is exempted from performing the 5 physical prayers and fasting, as long as she continues to bleed. Once the bleeding stops, even if it is less than 40 days, everything returns to normal, particularly her sexual relationship with her husband.

The fetus and the newborn have many rights in Islam. As any Muslim around the world, Nawal said that she followed these religious traditions that are a must:

1. Adhan (the call to prayer) is whispered on the right ear of the newborn as soon as he is birthed. Iqama (2^nd call of prayer) is whispered on the left ear.
2. Tahneek: is the rubbing of the baby’s cheeks with fruit dates (or honey) right after birth. (this is less practiced among the new generation)

3. Breastfeeding or wet nursing for up to 2 years (for those who choose to complete the term)

1. Aqiqah/Sebou’ (party day that happens on the 7^th day): A party for the parents to be thankful for the great blessing of having an offspring. They sacrifice 1-2 sheep to share the happiness with the community and feed the poor.
2. The Purifying (MALE circumcision): Among the hygienic purposes of the circumcision is the protection of the clothes, the penile, and the groin area from getting soiled after using the bathroom. Otherwise, this would nullify the physical prayer.
3. Naming the child:  this became one of the most fundamental rights of the newborn in Islam. That is why, it sometimes takes forever to choose a name. It is carefully picked by the parents and consultations are done with very close relatives. The name has to either have a positive and significant meaning in Arabic language or an Islamic one. The name is announced in the Aqiqah day. Nawal explained that her name in Arabic means generosity, gift, and kind characters.

7. The shaving of the baby’s hair: the hair is shaved, weighed, and the equivalent amount, in gold or silver, is donated to the poor. It is done on the 7^th day as well.

What Nawal likes about these traditions is that they bring the family and community together. Everyone feels that there is this an outpouring sense of sharing, helping, caring, and love.

She added that there are few non-religious rituals that are discouraged in Islam but very important to the Egyptian families. The customs that she doesn’t like or agree with are those concerning the evil eye. She thinks that her ancestors adopted them because high mortality of babies and new moms were common in the old days. So, for some people, those rituals somehow have an effect in protecting them. For example, the Sebou’/party day usually starts with scattering salt on the mother and around the entire house to keep evil eye away.

After bathing the newborn and putting on the new clothes, the infant is carried on a tour and followed by family members chanting and dancing while holding candles. The mother has to step over the baby 7 times without a single touch to the cradle. Meanwhile, the grandparents are making loud noises to intentionally make the baby aware of them. Gentle shaking to the cradle, while ordering the baby to obey the family, is done in a horizontal way and manages to comfort the baby, if startling. This is believed to strengthen the infant.

Taaweez: the practice of tying a black piece of string to a prayer contained in a small pouch is also very widespread among Muslim cultures although the religious scholars of Islam continue to criticize it on a regular basis. This string is usually tied to the baby’s wrist or around the neck. The common belief is that this will protect babies from ill health and evil eye.

Quran: Some believe that carrying the glorious book or putting it in the baby’s crib has a protective value as well.

Nawal wishes that the female genital mutilation is completely banned. It is a very common and practical custom in Egypt among both the Coptic Christians and the Muslims. Some believe that it dates back to the pharaonic area where it was used as a cosmetic measure. Others still believe that it is necessary to control female sexuality. Even though some Muslim scholars believe that it should be completely banned, there are others that support Al Khifad which is a much simpler procedure and is not regarded as FGM, so, they should never be used interchangeably. She clarified that Islam protects the woman’s right of sexual enjoyment. If Al Khifad enhances the wife’s sexuality and promotes her wellbeing, then it is permissible. However, if it would violate this right or harm her in any way, then it should be forbidden. She added that the procedure must be done only by a specialist in the field and the female has to complain of chronic infections, inflammation, or decreased sexual desire which are very rare.

Leila from Morocco

By Halima Sadki

Leila had a unique childbirth experience because she had one child in the urban side of Morocco and the other one on its rural side. She said that in the urban areas, moms are no longer giving births at home like before. The natural and unmedicated birth is replaced with a more complicated one in the clinics where moms could opt for a c/s just to avoid the pains of labor and delivery and the newborn is kept in a separate room so that mom could rest. The baby is formula fed all night long because there are no wet nurses in the clinics or hospitals. The mother is cared for in the clinic for few days and when she goes home, few people from the immediate circle would visit. Once mom is ready to finally start breastfeeding, either latch is difficult, mom is engorged, or supply is low, or she has no support. It is a very sad reality, she concluded.

The second time around, Leila decided to have her baby among her family in the North. There, hospital births are still rare and birthing in the clinics is expensive. As any pregnant mom, Leila appreciated the extra attention, the love, and the whole thing about pregnancy and birth in the traditional fashion. Of course, the importance lessens with the subsequent experiences but the atmosphere is still good and positive, she explained.

Although a pregnancy remains a secret until symptoms show, the mother is always assisted with most of the chores by female family members and neighbors. Once the cravings start, a special dish “Rfissa” is made to celebrate and announce the pregnancy to the community. It is a common cultural belief that if a mom craves a certain food and she is not able to have it, she might itch her skin, which would develop into a purplish birth mark after birth! So, the generosity of the community helps that mom remains well fed at all times. In the last week of her pregnancy, the pregnant woman’s mom joins her for moral support. She would take care of her and her newborn until the Aqiqah party.

In the religious tradition of the Nifass (post-natal bleeding) all kind of intimacy with the husband is encouraged, except penetration. This resting period allows a mom to eat well, breastfeed, and enjoy taking care of her infant. The end of this 40-day period is marked with one small party and is still exaggerated, in some places, with another month of rest at her mother’s house this time. This would allow a total of 2 months of rest as practiced by the ancestors.

Leila shares all Nawal’s religious traditions, since she is a Muslim too including the Adhan, tahneek, breastfeeding or wet nursing, shaving of the head, naming the baby, Aqiqah, and male circumcision. She explained that in the rural areas, they still feed baby honey and ghee if the wet-nurse is not yet available and mom has no colostrum. I asked her about female circumcision either among the Muslim or Christian minority females and she said that it is completely unheard of in the entire territory of Morocco (in spite of the fact that some scholars believe that it should be done if medically indicated following the Islamic guidelines). However, male circumcision is a must for every single male. One positive change is that people used to procrastinate on doing it if the birth was in the winter. They would postpone it until after weaning, then until after toddlerhood. It was even harder if done when the baby got older. Nowadays, people are getting it done much sooner again.

Because children are so precious and due to high mortality in the old times, few non-religious customs prevailed in Morocco too, just like Egypt. It was considered bad luck to buy items for the baby before birth or the gender was known. Also, it was a practical custom to put only old clothes on the newborn on the first day. Things are changing and neutral or new colors might be used now. Likewise, fear of evil eye is still common, mostly in low socioeconomic areas. For instance, some families will still keep baby hidden until the 7^th day. The same goes for the chosen name.

While the majority of Muslims use incenses because they purify the houses from bad odors and have benefits to the health and soul, some people like to believe that igniting them prevents the demons from entering the house, blesses it, and protects mom and baby from envy and potential injuries.

One practical and fun custom that Leila bragged about was the henna, which is done before the party. Her Kabla (traditional midwife) and her maids took her to the public bath. They massaged her body with oils and herbs and gave her a facial. The oldest lady massaged her tummy and the uterus. After that, they clothed her like a new bride. Everything was white and new. Beautiful Henna designs were tattooed all over her arms, hands, and feet and golden jeweler was put on. The baby was well dressed too. The Aqiqah feast is usually celebrated with music and ends with guests giving mom and baby gifts, money, and gold.

Unfortunately, the religious tradition of wet nursing is disappearing in the urban areas. Some new moms are satisfied with formula either because they have to go back soon to work or they live far away from work. Hospital grade pumps are rarely available. Breastfeeding in public, however, remains popular.

At the time of Leila’s mom, there was no specific prenatal care for pregnant women. Visits to the doctors were not needed if a pregnant mom was not suffering. Natural remedies and herbs were preferred over drugs. Old generations conceived very young, were pretty healthy, and averaged 8 kids per family. One advantage of today is the benefit of immunizations.