Recently there has been a ton of information made available to women about pregnancy, birth and the options they have. Some of this information is good, some of it is bias and some of it is so old school I wonder if even those writing it believe what they have written.
One of the new hot topics in the media is the Doula. Doulas have been written about in newspapers, popular culture magazines, medical and economic journals and even introduced to the TV audience. Yet who a Doula is and what a Doula does still seems to be such a mystery that the writers of such publications invent and twist to create the Doula they assume exists.
The most outrageous Doula impersonations seem to come from Comedy TV with witchcraft and sorcery at the center of the Doula universe. I am not sure if this is imaginary or if this is really how the medical community sees the Doula. Is the world really that fearful of choice that they would rather imagine what a Doula does then show the truth? I see today as my opportunity to set the record straight, to enlighten and educate and take away the fear. I am a Doula.
So let’s start with the facts:
Doulas are usually women, mostly because the intimacy of birth and popular culture views on sensitivity and compassion.
Doulas are not midwives.
Doulas do not catch babies, unless of course you are sitting in Wendy’s with a crowning head between your legs and you don’t want the 16 year old cashier to be the one catching, then maybe the Doula will catch.
Doulas do not perform clinical tasks, diagnose or prescribe treatment.
The Doula is generally under contractual agreement with the client as a private care provider, however several hospitals offer Doula based support.
Doulas do not contradict or sway clients, they do not suggest, expect or persuade.
The job of a Doula is to educate, support, advocate and comfort.
You might be thinking, well all of the above sounds good, so why all of the hype? To be honest, the Doula is a threat because she tells the truth. The truth is, birth is a big business. The labor and delivery units in some hospitals pay more annually to the hospital budget then the ER, intensive care and pediatrics combined. The business of birth is so big; many hospitals have focused their efforts on creating an inviting homey atmosphere to lure birthing families away from the competition. The competition being any person or facility that caters to birth. Obstetricians bring birthing families into the facility where they have privileges. The more births a practitioner does, the higher regard the facility holds them in.
Sounds like business as usual right? What if I told you that to bring in the big buck, a hospital has to create a mill like atmosphere? Every minute spent is a minute spending money. The less nurses the more money, which means equipment and intervention to relieve the nurse of her duties. The more scheduled inductions and surgeries the facility does, the more clients they can serve and the more money they can bring in. The hospital creates a business out of birth because to them birth is a business.
Think I am wrong? Let’s take a comparison shall we. In corner A you have an extremely competent Certified Nurse Midwife. This midwife has a top notch nursing degree and went to the best midwifery school in the nation. All together she has 8 years of collage and training with a specialty in women’s health issues and birth. She sees 8 clients a day and does 15 births a month. Six of the fifteen births are homebirths and the other 9 births occur at the local labor and delivery. She spends on average of 3 hours prenatally, 4 hours at a birth and 2 hours postpartum with her clients. Her epidural rate is 25%, her episiotomy rate is 5%, and she intermittently monitors her patients unless otherwise warranted. Her induction rate is 2%, her cesarean rate is 10%, which of course are performed by her back-up Obstetrician, and the average stay for one of her patients is 24 hours.
In corner B is an Obstetrician, very capable man, with 8 years of college training and a specialty in women’s health and surgery. He sees 25 patients a day, rotates on call with 3 other obstetricians and does 30 births a month, all the birth occurring at 2 birthing units at the local hospitals. He spends an average of 45 minutes prenatally, an hour at birth and 15 minutes postpartum with his patients. His epidural rate is 85%, his episiotomy rate is 45% and he has all of his clients monitored continuously during labor. His induction rate is 60%, his cesarean rate is 30%, all of which are performed by him, and his patient’s stays are on average 72 hours.
In these two hypothetical comparisons, which model seems more supportive of the emotional and physical well being of the mother? The midwifery model of care includes choice and unfiltered information. The midwife engages and empowers the birthing family to make the choices that are best for them. Which one would you think has better health outcomes for the mother and baby and which one is more likely to empower the birthing mother. I think we can all agree it is the midwifery model. Yet over 80% of births occur with obstetricians in hospitals in the United States.
Why? Hospitals and obstetricians use money-making tactics in their business. They purposefully create tender images, aesthetically appealing models, and advertise choice. But what really happen are standard protocols for all pregnant women, choices are removed and the provider and facility make the decisions as to what is “allowed”. The obstetrician handles all of his patients the same, giving the information he sees necessary and requiring tests and procedures to fill the gap of compassion and time. The obstetrician always has the larger add in the yellow pages, and we have all seen the commercials and full page color fliers delivered to our mailboxes exclaiming “birth your way”. Indeed birth has become the fast food empire of the medical community
So now we come back to the Doula. If she does not do clinical skills, if she does not work for the hospital and if she has not had years of schooling, training her how to think and what to become, then what use does the average family have for her anyway.
Think of it as the difference between buying a car blindfolded and choosing the one the salesperson says is the best, and having a mechanic and the Internet with you while looking for the right car.
If more birthing families requested the midwifery model of care, I am sure that the need for Doulas would be minimal. However, midwifery care although increasing, is still well below world standards for care. As a matter of fact, the U.S. is one of the only nations where women turn to a surgeon instead of a childbirth specialist for pregnancy and birth care.
The Doula does not expect your birth, does not manage your birth and does not filter the information and research that she gives you. The fact is the Doula engages the birthing family as the “in charge” entity and not the submissive patient.
For example, a woman hires a Doula for birth support and comes to her for information on induction. The woman’s provider has stated that the ultrasound says her baby is “large” and feels it would be safer for the woman to schedule an induction at 37 weeks then wait for the baby to “grow larger”. The Doula offers the client benefit and risk information on ultrasound accuracy, the risks and benefits of induction and birthing “big babies”. Information the Doula has gathered from medical journals and research documents. The woman reads this information and takes it to her provider. The provider agrees, ultrasounds can be wrong, and the baby may be a normal size. But still suggests induction to be safe.
In this example the ball has been left in the woman’s court as to what she might decide. The Doula has neither swayed nor pursued the woman to decide against an induction and is employed to support the birthing mother in whatever decision she might make. This allows the mother to make a decision based on her comfort and needs. She is allowed the opportunity to know all of the risks and benefits of the intervention thus allowing her an educated choice. She no longer is being sold something while blindfolded but able to investigate and research to make her choice.
So why would the provider see the Doula as interfering? Some of it may be that the provider is not aware of new research, many providers practice on the knowledge they gained during medical school and have little time and energy left to expand their knowledge with current practice protocol. The provider may not feel comfortable changing their practice principals. They might work with partners who wish to practice a certain way or a facility whose policies lean towards ultra conservative care. We must also acknowledge the hand of our legal system in the protocols and practices of many providers. The threat of lawsuits and legal problems may bring a provider to refuse choice to prevent such incidences. Whatever the reason the provider has seen fit to exclude certain aspects of choice and consumerism from his practice, that does not mean it is still not a choice indeed.
The phenomenon is that many birthing consumers have taken private provider protocol and facility policy as law; they see no room or even reason to challenge such practices. It is assumed that when entering a hospital to birth you must consent to ABC. This is simply not true and that the Doula reminds families of their choices and supports them in make such choices is where the threat lies.
If the Doula walked into the provider’s office and said, I will support whatever practice protocols you choose and assist you in convincing your patients to accept your decisions, the Doula would quickly become the hottest item in the medical community. It is the fact that the Doula reminds the consumer that they are indeed the ones in charge that disturbs the heavy end of the pendulum and creates the fuss.
But you say, what about the technology and interventions that save lives. You are right; these should be utilized and respected for what they can do. However, no matter the outcome, no matter the end result, it is the mother’s choice as to what she allows to be done to her and her baby. These choices should not be made under threat and coercion but under the pretext that she needs all of the information available, good or bad, to make the proper decision for her and her child.
Remember, after the birth, the family is left to it’s own devices. The facility caters to the next family, the provider refers them off to the next provider and the Doula eventually moves on to the next client. It is the birthing family and only they who live with the consequences of their choices.
So you might ask, what else does a Doula do other then provide research and advocacy. Doulas offer comfort measures such as touch, movement and physical support. The Doula expects the family to be the choice makers. She accepts low intervention birthing as normal, but supports fully when higher interventions are necessary. The Doula is the only constant presence available during birth.
As a general practice, the provider will come for procedures, in times of concern and for the actual birth of the baby. They generally do not labor with the mother or provide physical comfort during labor. The nurse is responsible for tracking labor and birth clinically, though charting and keeping the provider informed of the mother’s progress. The nurse is responsible for the clinical well being of both mother and baby should an emergency occur and in any 12 hour shift may be responsible for several women at one time.
The Doula arrives at the birthing facility with the family, helps them settle in and takes care of physical and emotional needs during labor, birth and the immediate postpartum period. She is responsible to provider the mother with the basic right of every person, comfort.
After the birth, the Doula supports the mother through feeding and recovery, offers physical support and resources to the family once at home and remains a community contact well beyond the birth needs of the family.