Simply Bearing Witness: Cultivating Boundaries for Empowering Practice

How can birth workers provide meaningful support while preserving the power of the people we serve? In this piece, Stephanie Lynn Tanner shares the importance of holding safe, intimate space while maintaining professional boundaries that support the autonomy and agency of our clients. She gives a few tips for creating a practice that is healthy and sustainable by becoming unattached from – and bearing witness to – the paths of the birthing women we work with. 

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Most midwives and doulas enter into birth work because of a strong desire to serve childbearing families. There is an abounding need for advocacy and improvement in maternal-child health, one that is very difficult to watch from the sidelines. Yet the outcomes we witness can be shocking – obstetric violence is real. Many birth workers have experienced this reality in their own lives. So our work often begins out of a visceral impulse to affect change.

However, trying to improve a dysfunctional system by allying with the populations subject to that system is tricky business. Birth workers are constantly riding the line between maintaining professional boundaries with our clients and creating deep intimacy that fosters holistic support. Many of us, seeing a lack of personalized, sensitive care, lean further in the direction of closeness with our clients, blurring the boundaries between professional and friend, risking our effectiveness as allies.

Blurred boundaries can happen when we are unaware of the limitations of our role or we internalize the outcomes of our clients. A common example is when a woman with a traumatic birth history serves as a doula in an attempt to prevent the same trauma from happening to others. Not only can this place an inappropriate burden on the client to have a particular outcome in order to fulfill the goals of the doula, but it may also compromise the doula’s identity if an adverse outcome occurs. Another example is a doula or midwife giving even a subtle emphasis on their values of certain birth choices over others. This threatens the autonomy of the client to make authentic and informed decisions about their own experiences, particularly when the client feels emotionally obligated to the birth worker.

Most of the time, these emotional exchanges are so subtle they are imperceptible. And our clients are not in an optimal position to realize that these imbalances are taking place. There is a sacred trust given to the birth worker during pregnancy and birth, which requires us to carry the responsibility for facilitating a relationship based on transparency and consent. However, many birth workers set the intention to cross into our clients’ emotional landscape, becoming entangled in their process and decision-making, in order to serve our own needs for connection and purpose. When this occurs, we take a great risk in disempowering our clients by taking on too large a role in their stories and making their stories our own.

It is possible to do this work and hold safe, intimate space while maintaining professional boundaries that support the autonomy and agency of our clients. How can birth workers create meaningful support while preserving the power of the people we serve?

Perhaps of the most importance is the need to resolve our own experiences. We put ourselves at a huge risk of countertransference when we go into birth work with trauma or bias. Countertransference is when a caregiver unconsciously projects their personal experience or desires onto their patient or client. It can express itself in many ways, all of which undermine the effectiveness of birth workers to be agents of change. The paradox is that when we go into our work with the mission to change the system “one birth at a time”, the births we attend are always held to the lens of our ideal, therefor robbing our clients of their ideal. When we attend births with our personal experiences set aside, we can show up fully for our clients’ story, keeping them in the place of power.

The second key point is that, although we have vast knowledge about the risks and benefits of the birth process, we cannot possibly know all of the factors for each of our individual clients. We have to let ourselves off the hook of being responsible for knowing what each birth holds for the person going through it. This means that what we may feel is unilaterally beneficial for all births may be the worst possible option for one particular client based on the richness of that individual’s desires, needs, and goals. There is just no possible way for us as birth workers to know what any one individual will need or want in any given moment. Our job is to simply clear the path for choices to be consciously made from a place of power and hold a sacred container for those moments to shine. To do this, we have to get clear on our preferences and set them aside. We have to cultivate a practice of humility and guard the power that is held solely by our clients

Third, we must be clear in our relationships with our clients. Just as caregivers can unconsciously stray into the land of countertransference, our clients can look to us to meet emotional needs that are out of our scope. Pregnancy and birth are vulnerable times where the need for connection and intimacy are high, which is why it is critical for birth workers to be equally vulnerable about the boundaries and limitations of our role. This means connecting our clients with the many resources that can serve as emotional support for the childbearing year, including therapists, healers, and other mothers.

Next, we must be mindful of how our desire to change an entire healthcare system can place an unfair burden on our clients. It is not their responsibility to bear the weight of our desire to change the system. In order to become good allies, we must recognize when our efforts are useful and when they undermine the support our clients seek us out for. There is a great difference between advocating for our clients (or a practice) based on what we know to be true and supporting our clients as allies in order for them to be advocates for themselves. Our efforts to change the system are much more effective outside of the birthing room when we organize as a whole using our experiences in the birthing room to inform our action. This not only will create greater change- it will also allow us to be fully present at each birth.

And finally, along with healing from our own personal histories with birth, we must take exceedingly precious care of our spiritual and physical selves. Self-care for birthworkers is essential to our ability to serve from a full cup, allow the individuals we work with to take full agency over their experiences, for us to provide information without bias or attachment, and to create a sustainable practice. Burnout is a huge consequence of witnessing obstetric violence, bullying, and discrimination while attempting to be emotionally and physically available. Burnout undermines our collective efforts to positively affect the maternal healthcare system and limits the already scarce access families have to competent, compassionate, and personalized care. We are an asset to our communities and must care for ourselves as such.

Cultivating awareness around what motivates us to do the work we do will go a long way in keeping the birth movement alive. As caring individuals who become professionals to serve the greater good, our humanity is what makes our care unique, yet makes us vulnerable to transference, countertransference, and burnout. Creating professional boundaries doesn’t mean becoming indifferent and detached. It simply means creating a practice that is healthy and sustainable by becoming unattached from – and bearing witness to – the paths of the people we serve.

Stephanie Lynn Tanner, RN, CHW, is a writer, nurse, community health worker, and mother of three living in the Black Hills of South Dakota. Stephanie’s passions for rural health and holistic nursing inform her work to bridge the fields of disaster preparedness, population health, and radical self-care. In this article she eloquently discusses the steps birth workers can take to practice self-care by creating professional boundaries and build a healthy and sustainable practice.