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Tuesday
Jul132010

Doulas & Homebirth

When I meet a doula, whether she has been one for a long time or just beginning, invariably, I hear the phrase, “I really want to see a home birth.” The next thing that comes out of her mouth is often, “Can I go to a birth with you? I’ll be quiet.” Or something to that effect. Having been a doula for many years before ever attending a homebirth, I totally understand the desire. Especially when the births she sees, one after another, are the typical, energy-suck, lack of empowerment type. 

While some homebirth clients will hire a doula, in my experience, they are few and far between. If she brings a doula along on the birth trip, I really enjoy it. I’ve often said there’s enough work to go around for how many hands are there (laundry, food prep, tending to kids, etc.). The doula is able to do loving support in a way the client needs from that woman. It doesn’t mean I sit back and don’t do any labor support, but the doula definitely has her own place on the birth “team” (if you will). 

One of biggest joys for women birthing at home is they get to choose who’s going to be there. Great thought goes into who they invite and who they do not. It can be excruciating when a family member or friend wants to attend, but the mom knows it will hamper her birth. When she says no, there’re always reverberations, but they usually get ironed out before the birth occurs. So, you can understand why it seems quite impractical for a midwife to ask her client if an on-looker can attend –just so she can see a homebirth. Hospital births foster voyeurism; homebirths foster intimacy. 

I’ve had doulas tell me they were sick of/burnt-out from hospital births and all they wanted to do now is homebirth doula work. In my world, that would mean the doula isn’t going to be very busy. 99% of women birth in hospitals; 1% birth at home and most of those do not hire a doula. Women in homebirths are very supported without a doula, whereas women in the hospital need as much support and love as possible. I understand how defeating it can be to watch birth after birth managed to hell and woman after woman have their birth plans flushed down the toilet, but even if all the doula does is be with the woman as a witness to the travesty, she has given the mother a great gift. 

On July 1, 2010, Nicole Murray wrote “Doulas and Unassisted Births in her blog Zipadee Doula. While I know that my writing about UCs is/can be controversial, I’m choosing to address this post for three reasons. One: there are doulas considering attending UCs Two: there are mothers considering a UC and deserve another viewpoint besides the rose-colored glasses view typically offered and Three: healthy, civilized discussion is always beneficial. Let’s try and keep it civilized, eh? 

(UC stands for Unassisted Childbirth. Not sure why the initials haven’t changed to UB, for Unassisted Birth; always wondered that.) 

Because I know of many doulas’ desire to attend homebirths, I find this entire piece a justification for/an excuse for doulas to be with women as they have their babies at home. It’s a clever way to be invited where they might not otherwise be when the mom has a midwife. 

Or might this be a backlash from doulas being pushed/shoved out of the labor room? 

Nicole mentions the semantics of when a person can call the birth a UC. On-going conversation about what constitutes a UC includes: is it a UC if the dad is there? kids? grandma? and now, add a doula into the mix. I can’t help but wonder if the definition of UC is expanding because more people are invited to the birth. Seems anyone and everyone can be there… except a midwife. Isn’t this odd to anyone? 

“A doula is not providing any medical care.” Hmmm. Nicole, neither does a midwife. Midwives provide midwifery care. In most of the licensed states, midwifery care is legally defined as separate from medical care. This is an important distinction; not only in semantics, but that the midwifery model of care is enormously different from the medical model of care

“Having that trust and relationship with another person can be a great thing at a UC, when often you are left alone to fend for yourself.” 

This line in particular annoyed me. “…left alone to fend for yourself”? Isn’t that the purpose of a UC? To be alone? Fending for herself makes it sound like she is being refused care, that there weren’t midwifery options for her (and I totally know that is the case for some women), not that she chose to give birth solitarily. That sentence colors the entire piece, drawing the woman as victim (of circumstance? of society? of a healthcare community?)… that others turned their back on her, therefore she is left to suffer on her own. This phrase also creates the illusion that she is Doula the Giving/Sacrificing/Supporting… that, otherwise, the woman would be bereft of any goodness to her birth. As cranky as UCers get about a midwife’s arrogance, doesn’t it seem odd not to comment about a doula creating a space at your births?

Nicole goes on to say, “After birth, she (the doula) can help clean up, make sure every one has what they need and help with settling in. She can be a person to look to for resources, advice and postpartum support. Having a doula on your side can ease the worries about not having anyone to turn to postpartum, because you are afraid of what they will think of your decisions. Women should not have to be afraid after their births, because they have no outside support.”

Can I just say, this is simply baffling. Seriously.

According to this piece, a doula fulfills all the roles a midwife does, except she is left without the safety net of a doppler and other potentially life-saving equipment. I mean, really?

What kind of alternate universe makes having the safety net the negative? 

Let’s look at this in the bright light. Doulas are hired. They’re outsiders. They know birth, usually pretty/very well. They make suggestions to the mom about positioning, making sure she eats and drinks enough, helps with the partner’s comfort, cleans up after the birth, helps with breastfeeding, makes sure mom and family are comfortable before leaving, goes to the hospital with mom in an emergent situation, knows how to contact emergency services and becomes an intimate part of the family dynamic as it relates to the birth. 

If a judge heard a doula describing the above actions, supposedly only “supportive” as they are, that sounds an awful lot like practicing midwifery –without a license. Is a doula willing to go to jail in order to “support” a UCer? It seems unlikely now, but it seems the doula-at-UC is a new-ish phenomenon. What happens if you are the test case? 

I encourage doulas to look closely at women’s motivation to bring them into their birth circles, but not a midwife. What are her expectations? Why does she want you and not a midwife? Looking from here, it’s a razor thin line between having a doula and a midwife at a birth. 

Nicole ends her post with, “Isn’t it a bit hypocritical to say that you support women, yet only if they do it ‘the right way’? If you feel uncomfortable with someone else’s birth choices, you can still give them the respect that they deserve as a person.” 

This, as most know, is where I struggle. As a very pro-choice midwife who talks about women having the right to a cesarean-by-choice, it makes me grit my teeth to think women have the right to UC –and that I might actually have to support them in their choices. It is hypocritical. It is. I have to feel it is cognitive dissonance at play. Cognitive dissonance is the experience of knowing what is right, yet doing the contrary. Knowing the risks, yet smoking anyway. Drunk driving. UCing. (Had to throw that one in there.) But, my own cognitive dissonance comes from knowing women have the right to their own choices, their right to self-determination, yet not giving acceptance/appreciation/the space for women to do just that. I think this is a topic all on its own, though, so I’ll let it percolate even more than it has been the past couple of years… write about it when the words/feelings find their light. 

Back to doulas. I love and appreciate doulas tremendously. Heck, I still doula myself. But, I think we all need to step back, take a second and consider the changing role the doula might be making in our birth world. Is doula as midwife what we really want?

Reader Comments (35)

Sigh. Wonderful post, and I completely agree. I have been asked so many times if I can attend a UC. As a doula, the answer is a resounding NO. I have a philosophical objection to UC's. Does this mean that I won't pat the friends of mine on the back that have had successful UC's? Absolutely not. But do I question their judgement? YES. The reason for that primarily comes from the fact that I know that birth is usually safe. USUALLY being the key word here - and as a doula I wouldn't trust my ability to identify when something is going south, and that means that most parents won't be able to either, sometimes until it is too late. I hate making a blanket decision about something based on the small chances, because it's one thing that we dislike about the medical community. But ya know what? I don't quite see it that way. If we line all the cards up right, safe environment, safe/appropriate provider, proper education, proper postpartum followup....those are the situations that end up the best. Why would we stray from that formula and tempt fate? I realize I am way outside the norm in a big portion of the birth community regarding opinion surrounding UC - but I am with you on this one. I would NEVER attend a birth as a doula in the role of a midwife. I am not a midwife, and logistically, who will be blamed when something goes wrong? The situation suddenly creates an under-experienced doula, which isn't true. A doula does not have the training to be a midwife, and we all need to stop pretending that it's enough. Could I, if need be, catch a baby? Absolutely. Could I, if emergency arose, assist a woman with shoulder dystocia, or a postpartum hemorrhage? Probably not. What business do I, then, as a doula have saying that it won't happen and if it does, it'll be okay.

Sigh. I have rambled long enough. Good post, I agree, and this topic INFURIATES me.

July 13, 2010 | Unregistered CommenterSabbath

This is very confusing. I thought the whole point of UC was to be alone, which I agree can be an enticing idea. If you are not alone, and indeed you are picking--and paying--strangers to be there, why wouldn't you want one with some midwifery/medical skills? Two in one! More bang for your buck!

But to say one thing about UCing is not rational is moot, since nothing about UCing is rational. If you look at the statistical likelihoods regarding safety, I mean. I understand some people think safety according to how it is determined by medical standards etc. is not the #1 priority, which baffles me, since for me it is just about my only consideration in reproductive terms, having a rocky history there, but okay.

At any rate, it seems likely to me that any doula who chooses to go along with this is really putting herself at risk, legally. I can't imagine that the most put-together of them would go along with such a plan, but people do odd things sometimes, hence UC to begin with.

July 13, 2010 | Unregistered CommenterAntropologa

Wow. Barbara, I normally completely agree with you.. and this time I nearly completely do. I was quite confounded at Zipadee Doula's post, it seems that she truly is attempting to take the place of a midwife.

But can I give you another perspective?

I support women choosing whatever birth scene they so choose. I support (grudgingly) hospital birth for low-risk women and totally for truly high-risk births, I support, unequivocally, home births with a skilled attendee, I support birth center births with the same, and I support UC because it is her right to choose that.

I have been invited to UC births before, but it normally never comes to fruition because of how carefully I outline my position. At a UC, my job would be childcare for their older children, cooking, cleaning, making phone calls... no birth related assistance... because that negates everything that they are hoping to accomplish by outside interference. When they realize I won't help, most women look elsewhere for other doulas who will be more hands-on.

As it is, though, my midwifery ideals/beliefs are that of more of a hands-off care and support, as much as can be allowed, so it should be no surprise that, if I support UC as a woman's right to choose, I would respect that choice in the face of mom attempting to convince me to attend a UC in a way that would make it a AC. :)

Which, might I end with, tends to be the conundrum that many UC advocates fall into.

July 13, 2010 | Unregistered CommenterCole Deelah

There are no grey lines for me about this. I remember meeting a doula several years ago who had routinely checked her clients cervices at home and arranged for some distraction allowing her to CATCH her client's babies, even in the hospital. She bragged about it! Her clients loved her because this gave her credibility and I was just thoroughly disgusted by it. It wasn't about what was safe for her clients, it was about bragging rights (in her particular case).

I draw a hard line- no matter what I think I know, I do not give dosages to clients, I do not suggest processes to start their labors. I do not interpret test results and there is no way in hell you'd find my hand in another woman's vagina unless my marital situation changed drastically, or my hand was in fire and that was the only place to find water. That's about it.

How do I feel about UC? I find it matters very little. I've talked with my husband about it and we've agreed that for legal reasons I will not attend them. I'm not willing to ever put my family at risk, that's just that. Maybe I'm delusional- anything can happen at any birth- but I'd much rather say "We were on our way to the hospital when suddenly..." or "The midwife had just called to say she was on her way, when all of a sudden.." than "Oh there is no provider and I am the doula." YIKES and double YIKES.

I know doulas who justify their checking their clients and giving what *I* consider to be midwifery care by saying that it is *women's* knowledge and that no one has a right to claim it. Well yeah, that's real pretty when you live in the forest with the fairies, and I'm not even disagreeing that it's true - AND the court isn't going to respect that line of thinking, I assure you. I'm not saying to practice defensively - I'm saying why practice aggressively??

It's interesting to me how we justify something as medical vs. midwifery care based on the point we're trying to make.

July 13, 2010 | Unregistered CommenterKristina

Barbara,

Thanks for taking the time to reply back! I would love to respond to everything you posted, but time is always lacking here.

Thanks for making the point about midwifery/medical care! You are correct, and now I know the difference :)

I did want to reply to the commenter who said that I wanted to replace a midwife -- I really don't feel like I am. While attending a UC, I would be performing the same tasks that I do at a midwife attended birth, and I don't think I'm trying to do anything the midwife is doing while she's there. I'm just doing what I always do as a doula.

When I wrote 'fend for yourself' (also, ha, I wrote that post in a caffeine haze, and it came out really quickly, so my post was not as well-thought out as I would have liked), I was thinking in terms of not having the emotional support from anyone, but it does come out as fending for yourself at your birth.

I may think and write some more on my blog another time about all this. I really did want to spend more time on the topic than I have been able to.

And really, the core of why I wanted to write this was about the disrespect I see from birth professionals when it comes to women UCing. I'm glad to see your thoughts on that, and would love to hear more.

July 13, 2010 | Unregistered CommenterNicole

Well written post (as usual) Barb. I, too, want to respect women's choices even though I feel that the choice may be inherently wrong for me (and for her). It's a troublesome topic :p

July 13, 2010 | Unregistered CommenterTiffany

Nicole, I don't want you to think that I don't support a woman's choice, but just like I question the intentions of the woman who goes in for an elective induction, I question the intentions of a woman who chooses a UC. I respect an individuals right to choose ANYTHING about their lives. My number one mantra at births, especially the difficult ones where I don't personally agree with decisions of my clients - 'it's not my birth, it's not my birth, it's not my birth....' I don't have to agree with a woman who chooses an epidural the minutes she walks in the door, but as her doula I do have an obligation to support her. And do so happily. At first I went through the internal struggle with these types of things, but I have long gotten over that.

UC, however, is where I draw my own personal line. Kristina said what I come back to all the time - I am not willing to put my own family on the line for the rights of someone to choose a UC with me as their doula. I feel that attending a UC alone is outside of a doulas scope of practice. Plain and simple. And the law, fortunately or not, agrees with me the minute something goes wrong. So, it's a really simple A+B=C type of equation. If I attend a UC, and something goes wrong, I am the most logical person to blame in the eyes of the law. I am not willing to go there personally, and would argue that woman and doulas that choose that put all of our abilities to practice in jeopardy by doing so.

So again in my rambling, I suppose I support a woman's right to UC, I don't agree with it, but it's her body, but I do not support doulas attending UC's. Not only is it legally challenging, but it has the very real possibility of turning into a game-ending scenario the minute something really goes wrong.

July 13, 2010 | Unregistered CommenterSabbath

Nicole: Maybe we should consider a dual-post (HA! I wrote "duel" first), sharing thoughts with each other about a topic... this one even.

I'm sorry it took so long to get this out... it took some... um... time? And gonads? *laughing*

I understand you *feel* you are doing what you always do at a birth, but, without a midwife, being a doula looks a *whole* lot different than when there is one. I still feel you (and the others) are justifying your presence.

And I just read the comment by the doula on your site about being yelled at by the midwife for attending a UC. As Kristina states above your comment, renegade doulas are the anchor on the barely above water homebirth/midwifery/birthing community. It's bad enough, the subset of midwives who holler about the evils of licensing, insisting on making humongous waves, confusing the people who might actually accept the prospect of midwifery... and now, there's the pretzel-ing of the definition of a doula. Who can blame the critics? We can't even keep our own selves within any sort of appropriate parameters.

July 13, 2010 | Unregistered CommenterNavelgazing Midwife

Thank you for clarifying to the world that the "midwifery model of care" is NOT a medical model of care. Espically a homebirth midwife!!

I still have not met one homebirth midwife, and they're all CNM in my area that is not "hands off" they all practice the midwifery model of care. and at homebirths that can include cleaning up afterwards and making something to eat for a client, or knitting in the corner as a couple cuddles.

Nicole maybe you need to follow the calling and become a homebrith midwife.

All the rationale will never change the fact that doulas don't belong at a UC . There is no role for you.

July 14, 2010 | Unregistered Commenterddewi

I know this post is more about the doula who would attend a UC than about the UCer who would seek out a doula, but I find myself baffled by why a woman planning a UC would even want a doula. The last time you wrote about UCers and midwives, I defended the idea of hiring a hands-off, just-in-case midwife, even though I myself am not comfortable with UC and would never even consider it. I try really hard not just to respect the right of women to make choices I disagree with but also their capacity as rational actors - even when I disagree with their rationale. Hiring a midwife just in case makes sense to me. Hiring a doula for labor support but not a midwife for her expertise with birth makes no sense to me other than for some sort of bragging rights to having birthed without a safety net. Can someone who has experience talking to these women please tell me they have a better reason than that?

I just had my second baby this past weekend, and compared to my first (an unmedicated pitocin induction in a hospital), I needed very little labor support and was very aware of what was going on with my body and with the labor. While I very much needed my husband to BE there, I didn't need him to DO very much until transition, and even then, I didn't need the kind of in-my-face, walk-me-through-each-contraction kind of labor support that got me through my first labor.

But when the baby's shoulders got stuck, I had absolutely no idea that anything was wrong until the midwife told me they needed me off the stool and on hands and knees NOW. The pushing stage had been going steadily but very slowly (this one turned out to be almost a pound bigger than my first, even though I gained 10 lbs. less with this pregnancy), and I would have just continued pushing, thinking I just needed to work at it more, until ... I don't know when.

So I can understand wanting to be left alone but still have a midwife around (though I don't know how much good they would have been in another room). But what on earth would a doula have done for me and my baby in a situation like that?

July 14, 2010 | Unregistered Commenterchingona

Excellent post. I wonder if the no-doula-homebirth thing is kind of regional. It seems that many (most?) homebirths in Colorado Springs are midwife+doula attended. Maybe it's just with whom I "talk shop." Meh.

I am all for doulas creating their own "philosophy of birth" statements. I even like that there isn't a governing body or board directing doulas' practices. However, I have sometimes wished there were a reference that delineates our scope of practice. How's that for straddling the fence?

Having no official definition of doula does create a gray area. I often describe myself with the popular blanket statement, "non-medical childbirth support." Well, yes, non-medical of course. But non-midwifery? Gray area. Should doulas, then, be very clear what their state's DORA (or comparable agency) defines as practicing medicine, midwifery, or nursing? ABSOLUTELY. And then not do those things.

What resonated for me in this post was your statement about the doula's role of *being* with a woman as a witness, that being the gift a doula brings to the space.

July 14, 2010 | Unregistered CommenterKatie

First, I just can't get past the thought that a doula would approach a midwife and ask to attend a homebirth with her? It is not the midwife's birth, it is not the midwife's home, and the guest list is not up to the midwife. Of course the midwife can insist upfront that an assistant or apprentice accompany her, but to later also tel the mother that a doula will be there too? For what purpose? What if the mother doesn't want a doula, or what if the mother hired her own doula? The presumption of that is just baffling to me.

Second, have you considered Barb that doula's become traumatized by their repeated exposure to hospital birth practices? Often times the mother herself is not traumatized by an incident, thinking that it was done to save her or her baby's life, but an educated doula knows better. I listened to an MP3 of a breakout session at, I think a CIMS conference, by Sharon Storton the founder of Solace for Mothers. The session was addressing trauma in doulas and the doula's there had some horrific stories to share that they were quite traumatized by. I know that women themselves who have experienced birth trauma sometimes turn to UC (and others turn to elective c-sections for that matter - but that is another topic), and I wonder if some doulas do the same? It makes sense to me that if a doula has been traumatized by hospital birth, and is now triggered when she returns to hospital birth, that she would be begging to see a homebirth and that a UC might be a welcomed experience. Her decision might not be based on logic or reason, it may be based on her exposure to traumatic experiences, her feelings of helplessness in that situation, and her frustration that the mother herself doesn't even see it and the system never changes.

July 15, 2010 | Unregistered CommenterJennifer Z.

Barb, I can't agree with you more. Especially in regards to your last comment on your own post.
I think one of the biggest detriments to midwifery care flourishing in the U.S. is the fact that midwifery itself is in such disharmony within itself... arguing and fighting over things like licensure and such and making it difficult for those not in the midwifery world to even understand what we are all about. The more disharmony and contention within our own midwifery community, the easier it is for the medical community to dismiss us and not ever legitimize midwifery as it has been done in other industrialized countries. I believe that doulas attending UCs are only going to further create rifts within the birth community and prove to those of our critics that midwifery really is dangerous.

July 15, 2010 | Unregistered CommenterStephanie

I completely, 100% agree with you, Barbara. I'm a new doula, only practicing since January. Being certified by DONA or CAPPA, there are standards that doulas have to abide by, including not giving medical care!. Yes, if it came down to it and there was an emergency, I could catch a baby, and generally know what to do. That knowledge comes with the territory. But I would never, ever put myself in a situation where I was the only "care provider" on purpose. Ever. Not only would I be risking my own self, but I would be risking giving Doulas and DONA a bad reputation. I could go on, but I'll refrain. Great post.

July 15, 2010 | Unregistered CommenterJill

Hey There-
I thought you might find this analysis of the most recent "Anti-Home Birth" study interesting.
http://www.themidwifenextdoor.com/?p=930

July 16, 2010 | Unregistered CommenterBecca

Ha, duel post might be fun. I'm not much for arguing things online, but a good discussion is always nice.

"I still feel you (and the others) are justifying your presence." --

My thoughts on that: I don't feel like I need to be at a UC. Or that I want to talk anyone into letting me be at their UC. I wouldn't dream of that. I guess I just want to let it be known that as a doula and past UCer, I support women in my area who choose to UC. I will be there to support them in any way I feel comfortable and able to. Just talking to other UCers around is wonderful to me. I know I lacked that community while I was pregnant.

I'm glad you wrote this. I like hearing all opinions, and I respect those who are honest about what they're saying. We are all different, and that's wonderful. It's hard to discuss something that's so controversial.

July 16, 2010 | Unregistered CommenterNicole

I think there is probably a place for doulas in homebirth, but not so much in the birth.

I've had two babies. The first was a planned midwife-assisted homebirth. The second was a planned homebirth, with the same midwifery practice, but I chose to transfer to a hospital for pain relief. Both of my babies have been malpositioned, leading for very painful, quite long labors, and halfway through the second one, as intense pain slowed labor down, I decided I didn't want to handle the pain anymore.

I was surprised at how much I enjoyed my two-day hospital stay. I had a steady stream of round-the-clock, supportive, non-judgmental, non-emotionally demanding, skilled help. If I have another baby, I'll have to post-partum doula or choose hospital birth.

Perhaps for many women, the help that family offers is flawless, but for me, and for many others, I know that that is not the case. Many of us have families who disapprove of our choices or who are struggling with fear. Many of us have families who are far away or who can't get time off of work, or have mothers and sisters who are ill or deceased.

I've read about post-partum doulas but I have yet to meet one of these legendary creatures. So many doulas want to attend a homebirth where they are not really needed, but what they ought to be doing is marketing post-partum services.

I loved my homebirth so much, but I loved the wonderful help I received during my two day hospital stay so much too! I really don't know which one was the better birth! If I have a third, I'll be looking for a postpartum doula, so that I can stay home and know I'll have the help to make those first days peaceful.

July 18, 2010 | Unregistered CommenterSara

Sometimes, the decision to freebirth with a doula is based on the inability to get a midwife-attended homebirth in high risk situations. Other times, it's about avoiding the regulation and risk assessment process of birth and the woman being completely in control of what happens.

The only part I'm confused about it is that some women will say that the decision to FB is based on absolute self-belief: belief in her ability to birth unhindered (and to know what to do in the event of additional manoeuvres being needed) and belief in her ability to "know" if something is wrong enough to warrant hospital birth. From that angle, I cannot understand why someone would want a doula in a midwife's role, unless the doula was taking care of other kids, preparing food and drinks etc.

July 18, 2010 | Unregistered CommenterMelissa

I have no idea where to start!

3 moths ago I gave birth unassisted to my second child. I consider myself lucky because it was the easiest most beautiful thing. I have some training as a midwife and volunteer as a doula for low income women. I had three options. Give birth in the same hospital I volunteer at, travel to Oregon and deliver with the same group of midwifes I had my first baby with or just stay home. After months of talking to other birth professionals and research I purchased a doppler and committed to an unassisted birth.

It was very clear to me what unassisted birth is. I feel like a lot of people have different opinions. I don't find it perfectly safe or even agree with the UC/UP movement. But in my situation I weighed the pro's and con's of all my options and felt the least amount of anxiety over just staying home.

My decision to hire a doula was a tough one. I worried that no one would help me because of my desire to give birth without medical or midwifery help. I worried that the doula would take me on as a client for the wrong reasons. I worried that she would over step her bounds or not feel confidant in her roll as support. Luckily my best friend had just finished her doula training and was willing to travel out of state to assist me.

My partner and I spent much of my labor alone while our doula cared for my daughter (and her ownl). When I hit transition and needed more support she stepped in and really helped me focus. She stuck to her job. Physically and emotionally supporting me while I labored those last few hours. Something my partner wouldn't have been able to do.

Never once did she give medical or birth advise. She listened to me reassured me that I would know what to do and eventually helped me pull my daughter out of the water as a friend and not my doula.

I am grateful and that doulas are willing to help women through unassisted births. I am confidant that it can be done safely and professionally. It is important for the mother and doula to remember that like with a hospital or home birth your responsibilities will change.

It is not the job of a doula attending an unassisted birth to give advise or resources. That is the responsibility of the woman and her partner, If she can not find the information on her own than maybe she should reevaluate her decision to UC.

It is never a doula's place to give medical advice or to preform and sort of examination. Most importantly in the case of a UC.

It is the responsibility of the doula to make sure the reason she is attending this birth is to support the woman in her journey. Not to get a chance at a home birth or to witness a UC.

My experience with a doula was incredibly positive. I worry that it was not because she was a doula but because she was a long time friend and we had months to discuss our wants and desires surrounding my baby's birth. It went quickly and without any problems and I am grateful, but have no interest in testing my luck and doing it again.

July 18, 2010 | Unregistered CommenterAshley

I spent a year apprenticing with a midwife and am currently a doula. Having attended a few beautiful births with very little intervention (periodic monitoring of the baby only), which seemed pretty uncomplicated and straight forward, until after the baby was born, I'm not personally comfortable attending a UC. As a new doula I thought it would be wonderful, providing emotional support, getting drinks and food, helping care for children. I didn't think about what would happen if the baby came out and wasn't breathing and/or mom started hemorrhaging. I think about those things now because I've seen them and know that a skilled care provider can deal with those situations. I can't and don't want to bear that burden of guilt, even if it doesn't include an investigation and charges filed against me as the most trained person on site.

I have friends UCing and am always grateful when the baby is born and everything turns out well. But I can't be there with them (not that they're all asking) because of the slight, ever so slight chance that something will go wrong that could have easily been prevented by a skilled professional who knew NRP or carried pit and could spot signs of abnormal bleeding before it became a life threatening situation.

July 18, 2010 | Unregistered CommenterRachel

I am going to try to have a baby next year but decided to started research. I did not realized so much to considered from type of birth to the minute matters of diapers. I want to have natural birth but undecided if I want epidural and hire a doula. I know for a fact I want a home birth now I got to convince my husband to be ok with it!

Thanks for the post it has given me some clarity.
Leslie

July 19, 2010 | Unregistered Commenterdoula los angeles

"She listened to me reassured me that I would know what to do and eventually helped me pull my daughter out of the water as a friend and not my doula."

i would argue that this situation is entirely different because the woman is indeed your friend, first, and then a recent doula on top of that.

July 20, 2010 | Unregistered Commentersm

As a doula, I've only attended one home birth, and it was a wonderful, wonderfully crazy experience. Personally, I would not attend a birth without a midwife or doctor present though. I don't have the proper training to be the only "expert" in the room.

July 20, 2010 | Unregistered CommenterKaren S

I debated whether to put this here or not...I am a doula and had a very traumatic experience with a homebirth.

I was asked to be a doula for a couple having their 5th baby, they chose to have their baby at home as Dad was a doctor. Family med/emergency med and had delivered babies before. I made my role clear, and told them I would not offer medical care/advice. I stuck to that role.

Labor went well, baby was born, a little meconium, but no issues. Dad took great care of baby and Mom began nursing. I went to leave them to start some laundry and heard Dad yelling to call 911. Mom had passed out several times and I came upstairs to find her vomiting with baby in her arms.

Long story VERY short...Mom had an undiagnosed placenta increta. She was taken to the ER for blood and IV pitocin as her bp had dropped en route. She was then transferred to L&D (to a different building blocks away) and taken to the OR. Baby was fine, but they were not able to save Mom's uterus, which was removed the next morning.

I, personally, would never attend a birth without a medical professional present...but in this case Dad WAS a medical professional. I have realized from this experience that I will redefine my guidelines to include a medical professional with an assistant, oxygen, and anti-hemorrhaghic medications. The outcome would not have changed, but the trauma to all involved (including myself!) could have been lessened.

Great post...we all need to step back from time to time and evaluate our own limitations.

July 20, 2010 | Unregistered CommenterSonia

Here in the expat community in Korea, most homebirths are attended by doulas and midwife or OB. I've attended 6 births so far, 3 at the American military hospital and 3 homebirths.

If someone wanted me to doula for a UC, I would tell them to hire a nanny and a housekeeper, they are plentiful here and could help in a way that would not be confusing. If UC'ers don't need birth help, but need support surrounding the birth, they should hire the appropriate professionals: nannies and housekeepers. Even when you tell clients that you are not providing medical support, there is still some confusion.

I also do not perform cervical checks. If a client really wants cervical exams before she goes to the hospital or calls the midwife, she can learn to do it herself. That is more empowering than having a doula do it.

I would not want to UC myself. I really appreciated having support around me for both my births. I had a doula at my c-section (for breech) and at my VBAC. My midwife-attended VBAC was very easy and I would have done fine without my doula, but having her there made it great. I felt totally in control the whole time with the exception of about 2 contractions when both my doula and midwife were right there.

July 30, 2010 | Unregistered Commentermamaseoul

Hmmmm

As someone who began "birth work" as a research assistant needing cord blood I find all this interesting and almost a good confirmation as to why I may never certify/ credential as a doula enroute to midwifery, or even advertise as such.

The roll I've played as "birthworker" never involves touching or inspecting mamas nether parts, listening to fetal heart tones or even assiting with her babe in any fashion until babe is fully born and handed to me by mama. Do I know how to do all this stuff... sure I do but why do it out of my scope, outside of a hospital, outside the law and without malpractice insurance.

I've always just been there to emotionally support the mother, To dance with her hold her or be held by her and sometimes just to sit still and pray inaudibly. On occassion because I know the medical lingo I've often been a good translater for the parents to be. For whatever reason hospitals seem to like that "support" person with enoguh knowledge to deflect the continuous question but probably just enough to make me dangerous. Heck I've even been the go between when mamas language was other than english and the rest of us only knew english. We communicated through eyes, moans and collective tears somethig I imagine requies too much investment for busy nurses on the floor attending to a dozen other birthers.

The last intended for homebirth I attend required a transfer. Mama and papa went in the ambulance with the midwife following. I stayed at the house waiting for the grandparents who were enroute from out of state. Now my role had transitioned to supporting them at the moms request so they wouldn't freak out and think the worst upon arriving to an empty house.

Later the midwife apologized to me that I didn't get to "go and see". I told her my role wasn't to watch and not a problem. I think she thought I need to document for NARM or something. Mama needed her parents to arrive untraumatized so that's the support I gladly provided.

August 5, 2010 | Unregistered CommenterFree

Leslie:

If you've already decided on a home birth then:

"I want to have natural birth but undecided if I want epidural and hire a doula. I know for a fact I want a home birth now I got to convince my husband to be ok with it! "

I know for a fact an epidural won't be an option in the US unless you anticipate a transfer and even then depending on why and when you transfer it may be too late.

August 5, 2010 | Unregistered CommenterFree

Free: All the things you describe are exactly what most doulas, apprentice midwives and midwifery assistants do; nothing very new there. Including the "translating," the supporting the family, the dancing with the mom, etc. All standard doula roles. Not to diminish your role, but to let you know those are what would be expected from a doula.

I never certified as a doula and never had lack of clients, either. I know there are factions that insist on licensing and others that equally insist on no licensing. I chose licensing.

But, not sure if you know, most midwives around the country have no malpractice insurance; it's offered in WA and FL because they're law is written requiring that malpractice insurance be offered. Otherwise, from what I understand, it's offered to the rest of us, but costs some $100,000 or some stupid amount. I do not have any.

And as for the mw telling you she was sorry you didn't get to see the baby born, I'd bet it had nothing to do with NARM, but everything to do with understanding that, for many women, being at the birth is an important part of the circle of birth work. That your mindset is different, and a great mindset, I might add, doesn't diminish her understanding that sometimes it's disappointing not to see the baby born.

Thanks for your work.

August 5, 2010 | Registered CommenterNavelgazing Midwife

"But, not sure if you know, most midwives around the country have no malpractice insurance; it's offered in WA and FL because they're law is written requiring that malpractice insurance be offered. Otherwise, from what I understand, it's offered to the rest of us, but costs some $100,000 or some stupid amount. I do not have any."

Actually had no clue that this was a case. I thought the uninsured or unlicensed were the renegade or allegal midwives everyone refferred to. Although I do realize it''s not required in my state for CPM's I was thinking about CNM's at the time of posting. Thanks for informing me...still so much to learn.

Ahhh you may be right about the midwife's intentions/ concerns. I just took it as being related to NARM becasue in an earlier convo she offered to provide a siggy if I had docs and even offer some placenta teaching. Sorry I didn't preface my statement with a back story. She's a fab midwife by the way and so supportive of apprentices.

Thanks!

August 5, 2010 | Unregistered CommenterFree

Hello, Lovely Barb,

Thanks so much for your support. Where I live, midwives are often not supportive of doulas at all at out of hospital birth, feeling like we are a criticism of their work if we are invited. I get to attend a few home births a year, and love them. I am myself a homebirther. It is great to hear a midwife say that all good hands are helpful.

I'm not into attending UC's. As a doula, I have a basic understanding of when things are looking odd, like lots of bleeding, or tons of meconium, etc. without the clinical ability to investigate it or do anything about it. If I feel like things might be odd, based upon things I've seen in hundreds of births, I'd probably feel the need to state my observations. And just doing that, I think, is making an "assessment", which is counter-doula. The role suddenly changes, and it would make me very uncomfortable, as I've just assumed some kind of responsibility. For one, if the woman wants a UC, my observation could be disempowering and create the doubt and negativity she's probably hoping to avoid, leading her away from her intentions and core beliefs. Yet if I don't provide the information I notice, my withholding something that might potentially endanger a mother and/or mother.

If the couple were extremely well informed, the father and grandmother, for example, were doing the "observations" and taking responsibility, I can totally understand how a doula's role would be very valuable in providing emotional support and comfort.

If a UCer wants a doula around to be able to say, "that looks weird" so they can transport, then why not just hire a midwife who will a) most likely be way more accurate in her assessment than i could be, and b) follow up and actually reduce the risk of transport to the hospital they wanted to avoid in the first place? If it's a sense of security they're looking for, a good, hands off unless necessary midwife would really be the most appropriate person. I know this isn't the only reason a UCer might want a doula, just acknowledging it as a potential point.

Doulas are knowledgeable of complications in labour without the ability to do anything about it. It would be very hard to only be there to clean up and do emotional support "no matter what". It's only an aspect of a doula's role in UC, but that's my small 2 cents.

These events occurred before the term doula even started to be used.

First of all, my homebirths were all VBACS and no CNM would attend them. There were no legal midwives who were not CNM's, and illegal ones were not easy to find. At my first homebirth, for my fourth child, I had a woman who had been to 30 births, some with an (illegal) midwife, and some with an old GP who delivered babies at home just as she had in the 1920's. My family practice doctor supported me in this and even met with her a couple of times before the birth. It turned out that he was on the phone with her during the birth. He came right away afterwards to examine me and the baby. He would have loved to be there for the birth but hospital politics prevented this. For my next birth I had an (illegal) midwife who had trained with the Santa Cruz midwives (this is all 1970's stuff.) Back then they were fighting episiotomy as a standard practice, and so there was emphasis on perineal massage, and to do that, I had to be in bed, which I hated. She and I didn't really hit it off. After that, not knowing anyone else, my husband and I did the births alone, always with the backup of my family practice doc. After we moved away from him, I did manage to get a CNM to come for my 9th. I hardly knew what to do with someone outside the family in my house and it stopped my labor for a while. I didn't think of this as choosing "UC" or what the definition of that might be. It was just the only way to stay out of the hospital.

I had a friend who had her first child in the hospital and then stayed home. She had midwives (illegal) for a couple, but then just had her babies with her husband there. For her seventh she had no prenatal care, and her husband took the rest of the kids to soccer when he thought she was in very early labor and would labor yet a long time. No cell phones then. She delivered all by herself, with no complications, but she told me that this was very lonely, and asked if I would come the next time. I lived 5 or 6 hours away, but told her I would try. However, she had to have prenatal care, not be anemic, and have a sonogram so she knew she had one baby head down. She complied, and I actually managed to get there well in time.
I contradicted her the couple of times when she referred to me as a midwife, as I certainly am not, but I did catch her 8th and 9th babies.
She would have stayed home in any case. I looked at myself as "just a friend."
I was also there when my daughter had her fourth baby at home. I had been present at her three previous uncomplicated unmedicated hospital births. The man in her life at that point wanted her to stay home out of an unreflective dislike of authority. He would have preferred that I not be there either, as he thought he needed no help, and his father who was an EMT would be there. My daughter insisted. It turned out that the baby's head came out and didn't rotate, and just sat there. The father and the EMT just stood there. So I took my arms out from around my youngest child and my oldest grandchild who were watching from the foot of the bed, threw myself across the bed, reached in, put my finger under the lower arm and started the baby rotating; it came spiraling out. The woman who helped at my first homebirth had done this for me, so that's what I had access to at that moment. I don't think this was true shoulder dystocia or it wouldn't have been that easy. And my daughter could probably have pushed harder, or gotten up on her hands and knees. But it seemed like the thing to do at the time and it worked out well.

I don't think I would go to an unattended home birth for anyone else besides my daughter or my lifelong best friend, especially not someone who was doing it based on the fact that I would be there. But I think you should remember that in a lot of places a lot of women have very few options between a hospital birth and an unattended home birth, and not judge them in those circumstances.

Susan Peterson

August 11, 2010 | Unregistered CommenterSusan Peterson

Thanks for visiting my blog! I began my doula working attending home births. Well, actually I became a doula as a starting point toward home birth midwifery. I've been practicing for almost eight years and although I have done a LOT more self-directed learning and attended more births I really am no closer to calling myself a midwife. There are times when I look at the older of the modern midwives and how they became midwives by training myself and wish I could do the same, but then I think about what that really means and realize that the safest way to go is not to even think about convincing myself I am capable (which I know I am when it comes to NORMAL births) but to follow through with finding a preceptor and completing my training, even if that takes years more (which may be the case as I have three small children myself). Anyway, rambling on here. As far as doulas and UC, there is considerable risk in agreeing to attend such births and I would feel very uncomfortable doing so unless I knew the mother well enough to know she was doing it for the right reasons and so was I, and I don't foresee that happening anytime in the near future!

August 12, 2010 | Unregistered CommenterNaomi

Interesting post and comments! I have had two UCs myself and am a childbirth educator and doula. I lived overseas a couple years ago and a lady contacted me as a potential doula client. Turned out she was planning a UC and asked me if I would still work with her, given my personal experience with UC. I agreed, but it was a very dumb decision on my part.

After a very, very long labor, I started to become very worried. The parents were taking it in stride, but then I started becoming a miniature midwife--checking the woman when she asked me to and I ended up catching the baby. Everything worked out fine. But in hindsight I realized that I had no business being there and that I was put in a situation I would never want to be in again.

August 25, 2010 | Unregistered CommenterAugusta

It's funny... after my complicated UC, I didn't get into any place where I felt I could "be" with another woman until many years later when I'd had a hefty dose of training. I guess I was scared straight? (so to speak)

What's really great, Augusta, that you said was how, with time, you, not only more anxious, but also used your hands more. This is exactly what happens in birth -both at home and in the hospital. UNLESS the practitioner is aware of that tendency and keeps it in check. That's a very astute observation on your part.

August 25, 2010 | Registered CommenterNavelgazing Midwife

As a doula, I agree with you. I am all for choice, but I won't be a back-door midwife. I also couldn't just witness a birth without assisting, I don't believe that birth is a spectator sport. I disagree with UC, while being very in favor of midwife attended homebirths. I would adore seeing more midwife attended HBACs, but in Pittsburgh, that is not very likely.

Doulas are there for support, not as a care-provider. It is outside the scope of our practice and our ethics to attend an unattended birth (and yes, just attending seems like an oxymoron). It also raises a red-flag for me when a woman fires her midwife but still wants me to attend her at home, just in case...

December 5, 2010 | Unregistered CommenterTeresadoula

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