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Breastfeeding and Doula Support

Rieko Kishi, a nurse doctoral candidate from the University of Illinois at Chicago, spoke with medical anthropologist Dana Raphael, Ph.D., the originator of the western concept of the "doula." They spoke about the doula's role in breastfeeding, Dr. Raphael's past and future ties to Japan and her long association with Dr. Kobyashi. Dr. Raphael currently directs The Human Lactation Center in Westport, Connecticut U.S.A., a nonprofit organization co-founded with noted anthropologist Margaret Mead.

Table of Contents

  1. Breastfeeding and Doula support
  2. Dr. Noboru Kobayashi and Mrs. Sotomi Oketani
  3. Message to future mothers

Breastfeeding and Doula support

Kishi: Would you talk about what you do at the Center?

Dr. Raphael: Well, we do many things. One of them, of course, is encouraging breastfeeding worldwide. That was our main service.

Kishi: And you are a medical anthropologist?

Dr. Raphael: Exactly, but I am also a "reflexive" anthropologist, which means that I tend to choose research projects about things that happen to me personally. For example, I chose to study breastfeeding, or breastfeeding failure, because it happened to me. I failed to breastfeed my first son and that started my study of breastfeeding.

When I couldn't breastfeed him, I was devastated. So what I did was go to the library and research what women in other cultures did to keep their babies alive. I studied this pattern in 178 cultures, and found that in every case, in every culture, there was a pattern of having some specifically named person come to be with the mother after childbirth. That person was usually mother's mother. One day a very dear elderly Greek woman was listening to a conversation between myself and her daughter-in-law. "Oh yes," she interjected. "That's a doula. That's the woman who comes across the street when there is a new baby, to help the mother with the other children." With that, the role of the doula was invented. The doula is the person who supports the mother so that she can breastfeed.

And you know Kishi-san, this is a really profound revelation. I had discovered that there was a physiological process (breastfeeding) that needed to have something in place in the culture or else the lactation function would not work. I don't know of any other biological process that needs the culture to supply support. In the case of breastfeeding, the woman had to have another person present and supportive so the let-down reflex would work.

Imagine if you had to have somebody come and sit down at the table with you so that, when you eat, the food would be digested. Breastfeeding needs support. And what happened was -- not only with me but it's been duplicated widely -- if you don't have that support, usually you cannot feed your baby.

Kishi: So when you had your first baby, you didn't have such a person?

Dr. Raphael: No, I did not and I failed to breastfeed.

Kishi: Yes, I read that in your book, "The Tender Gift."

Dr. Raphael: Did you read Dr. Kobyashi's Japanese translation of the book?

Kishi: No, I read it in English. You wrote that book many years ago, but I was amazed that you had already addressed many things and questions about doula support in detail at that time.

Dr. Raphael: Yes, and today I would change many things in that book.

Kishi: Please let me know an example.

Dr. Raphael: Some are very subtle. For example, every man in that book is called either a father or a husband, and, of course, now the appropriate thing would be to call them a "partner," because not everybody marries before they have a child.

Kishi: Ah, yes, because society has changed....

Dr. Raphael: Dramatically! Another thing is that we had to protect the breastfeeders in the United States during the sixties and seventies because there was so much negativity around breastfeeding. People used to think that the scientific pattern of bottle feeding was certainly preferable.

Today, it's a different story. Breastfeeding is encouraged by the World Health Organization and the American Medical Association, and organizations such as the Le Leche League and doula organizations educate women on how to breastfeed. So the acceptability of breastfeeding has changed considerably over the years. In fact, if a woman wants not to breastfeed she is sometimes made to feel she is a bad mother. Nonsense!

What's also happening now is an expansion of the concept of doula. There are now "obstetrical doulas," there are "hospice doulas..."

Kishi: Hospice?

Dr. Raphael: Yes, doulas who befriend and comfort dying people.

Kishi: I read they are used in adult intensive care units ("ICU") in hospitals, too.

Dr. Raphael: There's even an Ayurvedic doula. And the concept is very, very important. It's bigger now than just the breastfeeding issue. The concept is that we do need each other in many areas of our lives. And I just chose this one - breastfeeding - the need for someone to be there to help mother the new mother.

Kishi: Ah, I see. So when you see the concept of doula spreading globally you weren't surprised at it?

Dr. Raphael: Not at all.

Kishi: You expected it?

Dr. Raphael: Right. You know, I studied Alcoholics Anonymous, because that is a matter also of support. And what they do, in the most successful manner, is to have somebody - they call him or her a "sponsor" - one person who will be with you, that is your sponsor, who tries to help you keep from drinking. Do you know the AA - Alcoholics Anonymous program? They have it in Japan.

Kishi: Yes, oh,.... I also heard that in Denver they have a doula program for drug addicted people...

Dr. Raphael: What? Now you are teaching me!

Kishi: I did a literature review of the doula research and it seems that always, they have some positive results. I mean, I haven't seen any significantly negative results about the doula.

Dr. Raphael: Actually, there are situations where it does not work, and the mother really does not want to breastfeed. In those cases, it is very important not to try to force her to do so.

Kishi: Ah yes.

Dr. Raphael: Now we are working with women who have been sexually abused as children and we find that sometimes they don't want to breastfeed. Luckily, some do want to very much but, if they choose not to breastfeed, they should not be forced to do so or made to feel guilty.

Kishi: In that case, what can a doula do for them?

Dr. Raphael: What I see doulas doing is just showing them how to enjoy the baby and comfort the baby. Very often the mother gets extremely anxious. And I think doulas can make quite a difference.

Kishi: Ah, yes.... Doulas can help the mother not only in breastfeeding...

Dr. Raphael: Not only in breastfeeding but people are now making arrangements to hire a doula before they give birth and sometimes the doula goes through the whole birth process with the woman.

Kishi: Yes, "labor coach" became a main function of doula support nowadays, indeed. Actually, some doula programs, like the community-based doula model, start their support of the mother from the pregnancy stage on, and they also educate mothers about breastfeeding at that time. They talk about the benefits of breastfeeding.

Dr. Raphael: Sometimes those talks are very anxiety-arousing, if the mother does not want to breastfeed. And I think that people have to be very, very sensitive to that issue. For example, I have been working on educating the public about the issue of ritual abuse and torture by cults. We have had three sessions at the United Nations on that issue. The cults are small groups of people who form a secret community with characteristic ideology. They use their power to torture and sexually abuse children and women. One of the things that people do when they abuse children in these small cults is teach them how to dissociate, that is, to learn to take on other personalities. Have you had any experience with that?

Kishi: Like brainwashing, yes? Could you tell me more?

Dr. Raphael: Not exactly. They learn to think of themselves as an entirely different person so that they don't feel the vicious pain of the torture they are suffering. They may use the same technique when they are going through contractions. Imagine how difficult that can be if they dissociate when they are in delivery. Suddenly, the physicians or the nurses hear the woman talking about somebody else, or talking in a different voice. It is very upsetting to the medical team and they react in non-helpful ways to the mother. When I work in the hospital I try to make the interns, physicians, nurses and midwives aware that this sort of thing does happen so they will treat the woman compassionately.

Kishi: It must be very difficult for the medical staff to communicate with such women who are dissociating. As a nurse-midwife, I can imagine how difficult the situation could be. In fact, I used to plan to approach the medical staff to think about how important doula support could be. I thought that kind of preparatory education for medical professionals was very rare and wondered how to develop such non-medical skills.

Dr. Raphael: Reach out for their humanity, their empathy. It is very hard to get the attention of the interns, as you probably found out. Their curriculum is so full, everybody has a hard time getting their attention. Thankfully, articles such as this for Dr. Kobyashi's Child Research Net will help educate the public.

Dr. Noboru Kobayashi and Mrs. Sotomi Oketani

Kishi: How did you meet Dr. Kobyashi, and when? You were personal friends for a long time....

Dr. Raphael: Oh, we have been friends for over 30 years. One day, I was sitting in my office and I got a call from Dr. Kobyashi, who was in California, returning to Japan from London. When he was in London, he had read my book, and he thought, "Oh, this is pretty interesting," because hardly anybody was breastfeeding in America at the time; no one was writing or studying it. He asked me if I'd like to have it translated, and suggested he do it. I thought that was wonderful. And so we agreed to send each other material and keep in touch. Very shortly after that, I got a Fulbright Scholarship to go to Japan and promote the idea of medical anthropology in several universities. While in Japan I also talked about the idea of incest and sexual abuse. People asked me to come and help put on a conference on sexual abuse. So with the help of a second Fulbright Scholarship I again came to Japan and helped initiate the first conference on sexual abuse and incest in 1989.

Of course I am always working on this most consuming subject, breastfeeding. While I was there I met a wonderful woman named Mrs. Oketani who had formulated a method of working with women so that they could breastfeed. Is she still working?

Kishi: I don't think so. She passed away a few years ago.

Dr. Raphael: But are there Oketani midwives?

Kishi: Yes, yes, it is really popular among midwives, and I believe every Japanese nurse-midwife knows about her. I think many mothers, too. There is an Oketani school for nurse-midwives to master breastfeeding support.

Dr. Raphael: Wonderful... wonderful... I thought she was such a marvelous woman. She was a real doula to thousands of women.

Kishi: Oh... It is very amazing for me to know she is famous even outside Japan. Since I came to the U.S., I realized that breast massage is a unique Japanese culture of breastfeeding. The Oketani method is the most famous among several methods, but they say that it is very difficult for nurse-midwives to master the Oketani method and sounds almost secret. I wonder if the secret of breastfeeding support could be not the massage but the doula's presence, because not only you but also Dr. Kobyashi wrote about Mrs. Oketani, when he introduced doula support in his monthly essay a few years ago. Dr. Kobyashi met with her over many years and was impressed at her holistic approach. He referred to her as the Japanese doula. The concept of the doula is quite new in Japan, even though Dr. Kobyashi has been promoting it for many years.

Dr. Raphael: Great. In Dr. Kobyashi's program with children, how do you think you could get the doula concept across?

Kishi: I would like to approach new parents of children. I am preparing for my dissertation now, and I plan to make a comprehensive survey to understand women's pregnancy, childbirth, and postpartum experiences in Japan. I may develop a conceptual framework for doula support, and eventually would like to confirm the relationships between doula support and many outcomes. I hope every woman can receive necessary support when she becomes a parent.

Dr. Raphael: A lot of data exists now to confirm that supportive behavior really works.

Message to future mothers

Kishi: Would you have any advice for us? How could we provide or receive quality care for perinatal women in Japan?

Dr. Raphael: Well, the first thing would be not to force women into doing what they don't want to do.

Kishi: Oh, I see.

Dr. Raphael: And to find out very sincerely what they DO want to do. I know that women in our country are giving up their power. They are saying things like, "I don't care... I don't want any discomfort... I'll just get a Caesarian." Caesarians are performed more than 50% in some hospitals.

Kishi: Ah, yes, I've heard about that, yes.

Dr. Raphael: It's a nightmare. It's so tragic. And women are giving up their power. You know we fought so hard during the 1960's, '70's, and '80's. We fought so hard to get women this power and now it seems to me they are just giving it up. They are just not saying to themselves, "What really is good for me?" They are just following whatever is easiest and what they think will be less painful.

Kishi: Oh, it can be true in my country too. Even though a Caesarian section itself is sometimes necessary, giving up power is a real problem. But, culturally, Japanese women who tend not to speak up and keep harmony are considered good women. I would like to keep your advice in mind to share with other Japanese women.

Dr. Raphael: Well, you asked what kind of advice would I like to share with people. One of it is that... if they don't use the power that they have... it's just turning everything around, and they lose an awful lot. Besides, even a Caesarian Section is a major operation.

Kishi: So, you mean you think we might have more power than we think?

Dr. Raphael: We DO! There's a Quaker saying: "Speak truth to power," meaning talking truth to the people who have control and not letting them tell us women what is good for us.... To take back their control, at least of their own body and their own children. It pains me terribly to see what's going on.

I have to get back to Japan. I want to go very much! And especially the Kabuki.... Do you like Kabuki?

Kishi: Kabuki? Actually, I haven't seen Kabuki but I know it is an excellent Japanese art form. It is wonderful that you like it.

Dr. Raphael: Oh, I love it. Dr. Kobayashi used to laugh at me because I'd go at 11:00 and then have lunch and go back again for the 4:00 p.m. show.

Kishi: Wow, you really love Kabuki!

Dr. Raphael: Yes. They are such brilliant actors, absolutely so wonderful. What great artists.

Kishi: You have any plans to visit Japan next time?

Dr. Raphael: The plan is in my head but I'd like to get my body on a plane. Soon I hope!


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