If you ever had a crisis, Sarah Klein is the kind of person you'd want around. Warm, witty and caring with an unflappable presence, she makes you feel better the minute she walks into the room.
It's not surprising that Klein is a sought-after doula, in demand by mothers-to-be from all over Israel's South. Women look to her for all the things that a doula offers - emotional and physical support as they undergo labor and give birth, a helper to ease the child into the world, while relieving the mother's pain, stress and fear.
A doula "mothers the mother," as doulas say. They make sure the mother appreciates every moment of life's biggest miracle. Unfortunately, most of the mothers who want Klein's services can't have them if they want the additional peace of mind that giving birth in a hospital offers. This is because there is only one major hospital between Ashkelon and Eilat - the venerable Soroka Medical Center in Beersheba, which has a strict policy: A mother in labor is permitted to have only one person with her as she labors to give birth. She has to choose whether she wants her husband by her side or her doula - her labor coach, a woman who would make her labor easier and less painful, safer for mother and baby and far more pleasant for everyone. She can't have both.
Other parts of the country with a larger population and several hospitals to choose from don't face the South's situation. From the hospital's perspective, their one-person-only policy makes sense and was designed to protect patients. The culture clash does not involve blame or fault. Most acknowledge that Soroka provides excellent services for pregnant mothers and their babies.
But what Soroka doesn't do is permit a woman to choose to give birth in a more natural way. This lack of choice is frustrating to Klein and three other doulas in the South - not to mention the mothers who want their services.
Klein didn't grow up wanting to be a doula. She's a musician. Two weeks after making aliya from Boston in 1995, she was hired by the Beersheba Sinfonietta. Klein, who has a master's degree in music, still plays French horn with the Sinfonietta.
Not long after arriving, Klein and her husband Robert, an English teacher, became pregnant. "Even before I had my own baby, I had developed this passion for the birthing process," says Klein. "I read constantly. I felt a deep understanding of the incredible beauty of childbirth, including its spiritual significance - the direct connection women have with the Source. So in exploring my own options, I spoke to other women about their birth experiences and became skeptical about standard hospital births. I was considering having a home birth, and someone put me in touch with a midwife who did hospital births and home births. I had tons of questions."
The midwife, Hilary Kirshenbaum who has delivered some 7,000 babies during 27 years of practice in Canada and Israel, became Klein's friend and mentor.
"We decided that because it was my first baby, we'd be cautious," Klein says. "We decided we'd labor at home with Hilary and then, when birth was imminent, we'd go to the hospital and Hilary could deliver the baby. I'd still have a natural childbirth, but I had the security of the hospital if I needed it."
What did she not like about hospital births?
"Hospitals focus on efficiency. The first thing the hospital does is put you in bed - which, when you're laboring, is one of the worst things you can do. When you're lying down, you lose the natural force of gravity that helps move the baby down. Without the help of gravity, contractions hurt more and labor takes longer."
The Kleins' first two births both worked on that model - labor at home, then to the hospital for the delivery. During that time, Klein continued studying on her own and longed to become a midwife.
"If I'd known 15 years ago how passionately I love this work, I would have become a midwife. But to do it now would mean I'd need another BA, which would be tough with four kids. So Hilary suggested I become a doula. That appealed to me."
Doula is a Greek word meaning "female slave" or "handmaiden," a woman who assisted during childbirth. But there were doulas well before the Greeks. In the Bible, Shifra and Puah helped Israelite mothers deliver their babies during the period of slavery in Egypt.
When Klein became pregnant for a third time, she was disappointed to learn that the split labor/birth system wasn't feasible. "The hospital changed its policy. Now if I labored at home, Hilary would be able to deliver my baby only if she was on duty when I came in; otherwise, I'd have to use someone else. I couldn't take the chance that Hilary wouldn't be on duty. After a lot of thought, we decided on a home birth for this baby," she says.
"But it wasn't that simple," recounts Klein. "The baby started to come early, when Hilary was out of the country, so we had to make other arrangements. After a flurry of phone calls, we decided our best option was to drive north, near Rehovot where Hilary's back-up, Ilana Shemesh, lives and I'd have the baby there. It was a little scary - there are no hospital between Beersheba and Rehovot, so Robert and I waited until the contractions were three minutes apart, then we left. I grabbed the baby seat as I walked out the door, praying that the baby would sit in it for the ride home. We left home at 6:30 a.m. and I was constantly on the phone to Ilana."
The race was won, but barely.
"I got out of the car, but just then had to squat for a contraction," Klein recalls. "She walked us to her birthing house, and I was in heaven."
This was the birth experience of a lifetime.
"It was a big comfortable room, a bed with flowered sheets and a corner Jacuzzi. Ilana checked my blood pressure and the baby's heart rate, and everything fell into place. An hour and a half later, we had our perfect red-haired baby daughter. This birth was pure bliss - comfortable, quiet, and no pressure to hurry. In the hospital I'd had glaring lights, steel beds and other mothers laboring on both sides.
After the baby and I both rested a while, Ilana stood by while I took a shower. Then I put on my own clothes and went into her garden. It was like the Garden of Eden. There I was, nursing my two-hour-old baby in the shade of palm trees, blooming flowers everywhere. I'll remember that moment forever," she says.
On the way home, the Kleins stopped at the nearest hospital to register the baby and have mother and baby check-ups.
"The three of us were home about 12 hours after we left - with the baby riding in the car seat! I was so happy."
Klein's commitment to sharing this experience with other women grew. In 2005, she began studying for official certification as a doula.
DONA (Doulas of North America) International is a worldwide organization with some 5,500 registered doulas. "I started their six-month certification course in Jerusalem and loved every minute," says Klein.
Then came the fourth baby. If Klein's third birth was idyllic, the fourth was anything but.
"This time I was determined to have a home birth. I bought everything I'd need, and even got an oxygen tank from [the non-profit association] Yad Sarah. But again I started labor early, only this time I developed a high fever. Then the contractions stopped and I became very ill."
The following days were tense. Klein's fever, stemming from a urinary tract infection unrelated to the pregnancy, raged. Feverish and in pain, she she had no choice but to go to the hospital for treatment with antibiotics. Just as she'd feared, however, once hospitalized, she fell under Soroka's childbirth procedures. Connected to IVs and a fetal monitor, she was pinned to the hospital bed which, she says, slowed the natural birthing process. As the baby's heart rate fluctuated between normal and too high, she finally accepted drugs to induce labor. When even that didn't work, Klein was told she had no option but to undergo a Caesarian section surgical delivery of the baby.
Klein was devastated.
"The good news is that my wonderful baby is perfect. That's most important. But the downside was that it took me weeks to recover - not only from the pain of the Caesarian but also from the depression I suffered over how badly this whole birth process went. I had so wanted to have a baby born in my own home."
In time, a silver lining emerged.
"I've spent hours second-guessing myself, wondering if the fever would have gone away or if it would have spread to my baby. I finally gained some perspective and realized that I'd learned something very valuable: I've had four children, all with very different births. Now my own personal experiences will help me help other mothers who find themselves in similar situations. I'm a better doula because I've been through it myself. In that sense, it was a blessing."
What is it about standard hospital deliveries that natural childbirth advocates object to?
"Being put into bed, that's first," says Klein. "But from then on, hospitals operate like a conveyor belt, and one thing leads to another. Once a woman is in bed and can't walk around, her labor takes longer and her contractions hurt more - women don't realize that medicated births hurt more than natural births. To ease the pain, hospitals encourage epidurals [a spinal injection]. Once you've had the epidural, you're far more likely to need a C-section - again, the natural birth process is impeded. So once you take that first step, it's very difficult to call a halt. Each medical procedure leads to another."
Kirshenbaum, a former South African, has been a midwife at Soroka for 14 years.
"I'll tell you this - at Soroka both mother and baby will get the very best of care. But the birth will proceed on the hospital's active management model: The mother is in bed with an IV, she'll have an epidural, fetal monitor and, if there are problems, such as lack of progression or fetal distress, a C-section will be done," says Kirshenbaum.
Soroka is a busy hospital serving 60% of Israel's land area, with the highest occupancy rate in the country.
"At Soroka, our 10 beds in the delivery room accommodate 1,000 to 1,200 births a month, an average of 20 every shift. We simply can't allow friends or family members to run in and out during the hours of a woman's labor. But having doulas present would be different: If the hospital encouraged doulas, it would greatly benefit not only women in labor but certainly the hospital staff as well," says Kirshenbaum.
What about the other requirements, such as staying in bed and the drugs used to induce labor?
"Again, Soroka is extremely busy," Kirshenbaum says. "We have to move women along, make each woman's labor as quick and pain-free as we can - but being quick and pain-free carries a price. For the few women who want it, we just can't accommodate natural childbirth right now."
This raises another issue.
"In the South, very few women demand natural childbirth," says Kirshenbaum. "It's mostly a lack of education. If more women understood the benefits of low intervention births, then Soroka could and would offer these alternatives. The staff is ready to do so. But women are afraid of childbirth pain. They don't understand, so they demand epidurals. When they've had the epidural, they're more likely to undergo a C-section - and no one reminds them that there's no epidural for the pain they'll have after the C-section."
Would the hospital change its policies if women demanded more options?
"Absolutely," says Kirshenbaum. If enough women came in educated and prepared, with their doula, we'd drastically change the intervention rate. But making a change won't be an overnight activity. We have to start educating women about the need for prenatal care and then, as a part of that process, educate them about birth options. Soroka serves a very diverse population, including some groups that don't place much value on prenatal care. So we have to start there."
It may seem counterintuitive: Women who are educated about childbirth tend to prefer ancient, time-honored methods with the help of a doula. Those who haven't sought out the facts for themselves insist on all the science that hospital can provide. So Klein and a group of other natural-childbirth advocates are about to begin an intensive educational campaign aimed at women and at medical professionals about the benefits of a more natural birth process. They want everyone to know how much help a group of trained, professional doulas could be to the hospital's harried staff. If the hospital only knew, Klein and Kirshenbaum say, doulas would be welcomed.
"And if women only knew how much easier, less painful and more fulfilling a natural childbirth could be, they'd demand that option of their hospital," Klein asserts.
In the meantime, doulas like Klein will have to be patient. In Israel's South, the demand for a doula hasn't quite been born yet.
The following statistics were revealed among women who had the support of a doula:
A 36% reduction in use of pain medications
A 51% reduction in Caesarean births
A 71% reduction in use of drugs to induce labor
A 57% reduction in forceps and vacuum deliveries
An average of 1 hour and 38 minutes shorter labor
(Scott, Berkowitz, & Klaus, American Journal of Obstetrics and Gynecology, 1999)
Sarah Klein' s Web site: www.dulot.co.il/Sarah