The fight for birth justice: How doulas restore agency in a medicalised maternity system

Daily Maverick

7 hours ago

World Health Organisation(WHO) research indicates that Caesarean sections make up 21% of all births worldwide. By 2030, almost three in 10 babies (29%) are expected to be delivered by caesarean section. Although a caesarean section can be a critical, life-saving procedure, performing it without medical necessity may expose mothers and infants to avoidable health complications.
Inspired by a young mother friend's journey, Nathalie Viruly (30) a South African woman from Cape Town, signed up with the Zoe Project to train as a doula when she was in her twenties. Doulas are trained to provide emotional and informative support to a woman before, during, and shortly after childbirth.
The Zoe Project, which supports vulnerable women, girls, and babies through its comprehensive maternal health and empowerment programmes, collaborates closely with public health facilities such as Mowbray Maternity Hospital and Retreat Midwife Obstetric Unit.
The right to informed consent
Viruly described her role as a doula: 'to be a witness, but also a coach'. Describing her experience of working in public hospital maternity wards in the Western Cape, she highlights how many women have lost control over the birthing experience due to institutional protocols and lack of informed consent: 'Doctors often rattle off information and instructions to an expectant mother, and sometimes even gaslight her, making her doubt the realities of things that happen during the birthing process. The role of the doula is to say 'yes that did actually happen' and to translate instructions/information from doctors into mother-centric language that she can understand. '
As a 'witness', Viruly explained, the role of a doula is to validate a woman's birthing experience and help her to understand her options, the information and instructions given. She explained that ' it's being (the birthing mother's) advocate in a sense… knowing what questions to ask and to stand up at the right moment — i.e. in an instance when a doctor may deny her experience. The role is (thus one of) being an advocate, a translator, and a coach. '
In an era where birth is increasingly clinical, doulas like Viruly act as translators, advocates, and protectors of women's rights: ' It's about knowing what questions to ask and when to stand up — especially when a doctor denies a woman's experience.'
Viruly's activism is rooted in restoring agency to the birthing mother — not by rejecting medicine wholesale, but by resisting its totalising authority. 'It's not about going to war with doctors, ' she says. 'It's about ensuring women know their rights and can participate fully in decisions about their own bodies.'
Doulas are not medical professionals and as such have no medical training, however they play an ancillary role to women who 'often come (to the hospital) very much alone ', says Viruly.
In a recent South African study at Pelonomi Tertiary Hospital in Bloemfontein, 81 % of fathers were absent at delivery, even though 50% had 'planned to attend'.This aligns with global statistics, which estimate that even in cases where fathers are physically present, roughly one in five may be 'uninvolved' at the exact moment of the birth taking place.
Doulas occupy a contested space in healthcare. Although they lack medical licensure, they operate with professional training, a service ethic, and deep experiential knowledge. In part owing to the glorification of biomedical professionals and strict 'dossier definitions' of 'healthcare workers', many doulas were let go of as 'non-essential staff' during the Covid-19 pandemic.
Though Viruly wasn't 'laid off' in the strict sense of the word because she was a volunteer doula, she was effectively told she was 'non-essential'. She is now working as an art curator. Her story reflects how narrowly 'healthcare worker' is defined in systems that privilege biomedicine over holistic care.
Activism: the fight for birth justice
Data from the WHO indicates that there are significant discrepancies in a woman's access to choices between C-sections and natural births, depending on where in the world she lives. In the least developed countries, about 8% of women gave birth by Caesarean section with only 5% in sub-Saharan Africa, indicating a concerning lack of access. About 1.9 million stillbirths — babies born with no sign of life at 28 weeks of pregnancy or later — occurred worldwide in 2023. Many of these might have been prevented with proper care. This begs the question: are women free to make their own choices about how they give life, and if so, 'choice' under what circumstances?
The fight for birth justice represents resistance: standing for informed choice, bodily autonomy, and maternal dignity in spaces where these are too often denied.
The cultural roots of over-medicalisation
Anthropologist Robbie E Davis-Floyd famously critiqued the 'technocratic model of birth' in American obstetrics in the 1980s, describing it as a cultural belief system that treats women's bodies as machines to be managed.
Davis-Floyd (1987) notes that 'the hospital operates like an assembly line, with labour and delivery processes geared toward producing a perfect baby, often at the expense of the mother's experience'. Obstetrics, Davis-Floyd writes, is unlike other medical specialities, in that it does not deal with true pathology in most cases it treats (most pregnant women are not sick).
Obstetrics as it is practised today is challenged by the natural childbirth and holistic health movements that critique the biomedical method of managing a birthing mother's body as if it were a 'defective machine'.
Birth activism in a broken system
The reasons for the increased C-sections are complex: risk management, institutional convenience, legal pressures, and in some cases financial incentives. These justifications nonetheless reflect a profound distrust in women's bodies and a systemic sidelining of their voices.
Genesis Maternity Clinic, once a sanctuary for natural birth in Johannesburg, permanently closed in 2023. The closure, wrapped in corporate platitudes, signalled not just the loss of a facility—but of an idea: that birth can be both safe and centred on the mother.
Although the press statement on the closure issued by Life Healthcare Group (the clinic's owner) stated that 'there are several quality private natural birthing clinics in Gauteng to consider', this was unverifiable. The statement goes on to thank patrons of the sunken ship, as well as the as well as 'employees […] midwives, doulas, obstetricians, paediatricians and other allied healthcare professionals.'
Together with the WHO stats of increased C-section rates globally, the closure of Genesis in Joburg and Viruley's 'lay off' in Cape Town makes one wonder if there is no fight left against medicalised motherhood, or are alternate methods just not popular or not offered much anymore.
Whose choice is it really?
While some women are denied essential medical interventions, others are subjected to them unnecessarily. Globally, about 1.9 million stillbirths occurred in 2023 — many preventable with proper care. Meanwhile, in the US, a C-section can cost upwards of $13,600 (about R230,000). Geography and economics often determine not only birth outcomes, but whether a woman has a say in how she gives life. DM
The Zoe Project
Based in Cape Town, this nonprofit organisation is dedicated to supporting vulnerable women, girls and babies through comprehensive maternal healthcare programmes. It provides:
Doula/birth companions: Providing emotional and physical support during labour and delivery.
Antenatal classes: Educating expectant mothers on pregnancy, childbirth and newborn care.
Postnatal support: Assisting new mothers with breastfeeding, nutrition and emotional wellbeing.
Bereavement doula services: Offering comfort and guidance to families experiencing pregnancy loss or stillbirth.