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Saturday
Dec012012

Doulas at Unassisted Births

A recent post on Facebook provoked a slew of comments that brought out the polar thoughts on the topic of doulas at Unassisted Births. I started the argument with: “Doulas attending UCs make me CRAZY!” That got ‘em going. Here, I share the most cogent of the discussion, with a few of my added interjections.

JT: So women who choose to UC don't deserve the support of a doula?

NgM: No

JT: Wow. That's messed up. Unassisted does not mean no outside support. It means no birth professional such as an OB or midwife. At least in the birth world I belong to.

NgM: What happens is doulas become the professional at UCs. They get asked questions about safety. They get asked if something is normal. They get asked if a transport should occur. Doulas are NOT just there as doulas; they become the professional. THAT is why a doula has no business at a UC.

DJ (who said it better than I did): A doula attending an unassisted birth may be considered "the most experienced and educated person in the room" and therefore the most liable. Philosophy and ideology aside, it just doesn't seem wise.

CU: I'm conflicted about this. Years ago, when I was a doula, one of my clients decided not to go to the birth center or hospital after 72 hours of PROM. After she said she would just do it at home if she had to, I consulted with colleagues and told her I would not be the only professional at the birth. The mother was PISSED and fired me. Do I think she deserved support? Of course. But it's not fair to be the only paid, trained person there--it's not fair to the doula. Better to ask a friend or a family member, rather than to hire a doula, IMO. By the way, I was flamed all over the (anonymous) internet for what I did--everyone responded saying that I abandoned her and was acting selfishly. Sigh.

DJ: Why can't I decide when to move my child to a booster seat? I know my child better than anyone.

NgM: I think any doula who goes into a UC situation is asking for trouble. She could end up in jail if anything untoward occurred, her being the most professional at hand an important legal point.

KJP: That may be correct NGM, but it's still of the utmost importance to protect the choices mothers/families have in regard to who they want at the birth and what kind of assistance, if any, they desire.

WB: But believe so strongly in the services they provide I women so they risk it!

DJ: Women who choose unassisted birth can choose nonprofessionals to be present with them. Since when does the need for emotional support trump the need for medical guidance? If you feel you need any professional in attendance, and not simply a family member, then what are you really thinking?

LS: I don't feel that it matters if it’s a friend or family member or random client. If they are planning a UC, you become liable. If something goes wrong, the doula present becomes the face of doulas everywhere, just as a midwife at a mw-attended home birth becomes the face for all of those tragedies when that goes awry. The situation could bring you under legal proceedings by local authorities seeing you as an unlicensed practitioner or the parents could decide you had a hand in the child's fate. Simply a bad place to be, IMHO. You stake the well being of your own family and finances on being the only birth professional present by contract.

AO: Doulas are not birth professionals and you seem to not really understand what a UC really is and the work, and the emotions that go into planning and having one, birth is not a medical event so why do I need medical assistance?

NgM: Doulas sign contracts. They are, indeed, birth professionals. I/We do understand what UCs are and the work that goes into them. YOU might not consider birth a medical event, but legally, it is.

GB: That may be true, but that is not up to you or anyone else to decide FOR anyone else.

AO: Doulas are support, not care providers.

NgM: That’s true, but doulas offer an enormous amount of information to women including options in birth and when things might need to be changed if stuff is going wrong. Doulas carry a lot of weight with responsibility and women put them in that position.

DJ: But being the only professional present gives the appearance of having some responsibility. At least that's the way the law sees it. Hence, you are at risk of "practicing medicine without a license." It doesn't matter what your intentions are. You can argue whether it should be that way, but that's just how it is.

TB: A doula decides for herself what is in her scope or not (or her certifying org decides for her if she is certified). If a doula is comfortable attending UC, clearly states in her contract AND to her client exactly what she does and does not do, then its really between her and her client. Just BC you don't want a doula at your UC doesn't mean it wrong, stupid, risky, etc for everyone else. As a doula I like to support my clients however and wherever they need it. I also don't just take anyone, and would be especially picky with UCs. I do not become a "medical professional" even if there is not one at the birth. My role is still the same, I still don't provide medical support.

NgM: A doula can have every intention of staying “non-medical,” but when the shit hits the fan and the mom starts asking questions, what’s the doula going to do? Say, “I don’t know,” when she does? Or is she going to help the woman save the baby’s life. We know that answer.

AT: Wow. Selfish to want to have support without medical assistance. Nice to see why we can't get things changed in the birthing community. We're too busy worrying about whether everyone is doing everything just right by everyone else's rules.

ED: But a doula is NOT a medical professional. That's like saying the photographer would somehow be the "default authority" in court or something.

NgM: A photographer does not have training in birth. That is a ridiculous comparison.

AT: Frankly, a woman will ask a doula if something is wrong no matter what. Women look to doulas for many things when they're scared in labor. In which case, the mom probably shouldn't be UCing. Having no medical professionals there doesn't change the situation. If something happened while waiting for the midwife to arrive or on the way to the hospital, the doula would be at risk. Being at a home birth period is risky for the professionals, no?

DC: I have had a UC with a doula there. She was only there for emotional and physical support, not medical advice. I was not scared and I didn't ask her for medical advice, like someone here said all women do. It was wonderful and 100% complication free.

NgM: But, what if there had been complications? What if you had asked for advice? What if you were scared?

ASM: It's her uterus and her choice. And I stand as a (soon to be) fellow that supports her choice to birth as she feels right (TBA student). Until then, I take my risk at jail time for serving UC's as a doula. Because I serve women. And I accept risks for what is right for her. But that is my choice and mine alone. And I don't give a flip what anyways else says. Women deserve a choice.

CM: Hey, doulas shouldn't do something because they might be held liable or arrested...

Law = justice = truth = the right thing always, right?

We all have the obligation to do right by each other, support each other, love each other.

Fear driven care, whether midwifery, doula-ing, ObGYN practice is dangerous for women.

O: I really love your blog but this time have to respectfully disagree. Doula isn't a medical professional and doesn't 'attend' birth in that capacity. She is not intended to replace a medical professional but support the mum. Freebirth is a legal right and a woman's choice and contrary to popular belief - far from reckless. Some UC mums might want a doula and if they need one - they should be able to have one. There's nothing wrong with a doula at a freebirth.

NgM: Again, she might have every intention of attending in a non-medical capacity, but if complications arise during the birth, she will be thrust into a whole different scenario.

ES: Someone who puts "doula" in her name is the same as a mother or grandmother who has helped other mothers through their births in the past and brings support, wisdom, etc. they both have every right to attend a UC if the mother desires and if they cross the line into medical advisers then that is their own risk, but they should not be banned from all UCs simply because that risk exists.

NgM: Now that’s a clever comment.

AY: I've not taken on clients in my doula role if they want to UC. You can be prosecuted for acting as a midwife and if you are there even in your doula capacity and something goes wrong it's a huge risk to take that the CPS would understand the difference between doula and midwife etc. and not prosecute. For my own safety I wouldn't attend.

JL: I can put sparklemummy in my name and treat you like a sister but because I am a trained person if you we're choking I'd bang you on the back and do abdominal thrusts because I am also a nurse. If a traditional untrained midwife is there acting as doula and something goes wrong she will use her skills! And thus she will be in the shit. And so will you because she has no Ob backup no O2 and can't intubate.

NgM: Lastly, I think this poster speaks for many of us in this field, those who want to help, but are constrained by the fear or the law… or fear of the law. She says this eloquently.

SM: I have such mixed feelings about the matter and really don't think there is any good answer in place yet. On one hand, a doula is putting herself out on a limb legally by attending a UC, whether or not the mother has any intention of holding her responsible for problems. The state doesn't require the mother's consent to do that. If that was not the case, if there was some way to protect the doula, I would be completely in favor of a doula's choice to attend medically unassisted births.

On the other hand, when I had my third child and wanted to give birth in NY near family, having the baby with only a doula seemed like the best option at the time. All I expected from her was counterpressure to help with my back injury. My husband was NOT capable of that and nobody else lived close enough by to commit to it. As it turned out, my sister completely missed the birth.

If I was to have a fifth child, I don't know what I would do. And if I was to start working as a doula again, I still don't know. It's just complicated.

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Reader Comments (15)

I have already decided not to attend home births as a doula for this reason, whether a midwife is present or not. UCs are a big NO.

December 1, 2012 | Unregistered CommenterEC

I know we struggle with this within our own community. How birth support and professionalism and mothering a mother can get mixed in with legal responsibility. Anyone who attends that birth is legally responsible with whatever the outcome is. As soon as that mother looks to the doula for guidance or decision making, she becomes liable. What would you do, as a doula, if that birth resulted in fetal demise and the parents decided to pursue legal action? I think if you are attending UC births as a doula, you need to ask yourself this question. Clients may seem trustworthy, come across as a friend, however in the future dependent upon the outcome may change their tune. If you go through a certain organization for your training (DONA or CAPPA for example), those organizations may choose not to stand behind you or provide any legal support. Yes, it would become a witch hunt (which we have seen in the legal battles of midwives), and it may be team parents or team doula - but, in the end, what leg do you have to stand on? I think each person present at a UC beyond the birthing family needs to examine their role and what their stance would be if something were to happen. You may still choose to support that family, but remember that you could be called to testify. Are you prepared to do that? Ask yourself that before you open the door, and remember that birth rates around the world and statistics might be a world of hurt for you. I don't UC myself, however those families who make the choice to UC are doing so for their own reasons. JMO - but within a professional scope, attending UC is not something that is outlined in scope of practice at all. Just like anyone can call themselves a doula without formal training - she may be experienced in offering birth support, be charging for her services, and outlining what she will/will not do. Or she will be an intuitive spirit guide for that birth.. in the eyes of a court, if you are there guiding a family, you would be held liable and may face charges if the family decides to do that post-birth.

December 1, 2012 | Unregistered CommenterKnottyrhonda

What timing! I attended an UC Thursday. It was peaceful, beautiful, completely unhindered. I knew that it may not have gone that way, and I chose to accept the risk anyway. It took a lot of deliberation to come to that conclusion, and I drafted a contract specifically for this family because I felt it prudent to protect myself in that way. It was an honor to be included in this very private moment. If I am invited to attend another UC in the future I will wiegh it with the same careful consideration that this one got because every birth is different. When
we start making blanket statements and use words like "never" and "always" we do our clients a huge disservice.
A related question; What do you think about a midwife agreeing to be on call for an UC should the family decide that they need one last minute?

December 1, 2012 | Unregistered CommenterBJ

The root of the issue is this: birth is not a medical event...until suddenly it is. And that is why as a doula, I will not attend any births that are not being overseen by a licensed medical provider, recognized by my state. Should fear govern our actions? To an extent, I say yes. It is not so much fear as concern and respect for the unpredictability of the birth process. I do not feel all birth choices hold equal merit when looked through the lense of safety and health for mother and baby. Therefore, I choose to avoid putting myself at risk and also avoid going against my innermost voice (and personal research) that tells me birthing without a qualified care giver carries MUCH more risk than even an induction of convenience or unnecessary cesarean, to both mother and child. /rant

December 1, 2012 | Unregistered CommenterDJ

Three things:
[1] In this entire exchange, the word "BABY" isn't mentioned once, and the word "CHILD" only twice, and then not in relation to a specific birth. There is something immensely twisted about this because the whole point of giving birth is to deliver/be delivered of a healthy baby. Birth IS NOT about the mother, who is merely an incubator, it is about the BABY, who [surprise, surprise!] is a HUMAN BEING, too.

[2] Doulas are NOT professionals, and any doula who acts as one ought to be prosecuted. It precisely because they too often attempt to pre-empt the role of professionals [it usually happens when the professional tells the pregnant woman something she doesn't wish to here] that I think they should not be allowed EXCEPT within very narrow parameters and be supervised by true medical and nursing professionals.

Of all the fads connected with birth I've encountered in 40 years, and I've encountered quite a few, UC has got to be the craziest, and really plumbs the depths of stupidity and irresponsibility -- for both mother and baby, but especially the baby. Occasionally -- very occasionally -- a birth is so precipitate that the proper assistance cannot be summoned, but deliberately planning a UC ought to be considered a psychiatric aberration. When a person becomes a danger to herself, and to her infant, she ought to be committed to the proper psychiatric facility.

Is this harsh? It's meant to be. The willful avoidance of all professional help on the most dangerous day of a woman's life is not something I take casually. We have come to believe that birth is always safe, always has a happy ending. It isn't. Nowadays, it isn't common to have a friend or relative die in childbirth, so it's easy to pretend that it never happens.

December 1, 2012 | Unregistered CommenterAntigonos

A related question; What do you think about a midwife agreeing to be on call for an UC should the family decide that they need one last minute?

Not much. In fact, I think even a CNM should be very wary of such a situation because she is damned if she does, and damned if she doesn't. If she is called, finds a situation requiring transfer but the patient refuses to do so, or the transfer takes so long that the mother and/or baby are compromised, she will be regarded as liable. And let's face it, she isn't going to be called if the labor is progressing normally. OTOH, should she decline to assist, she is also liable should anything go wrong, by withholding her services.

This, again, is why midwives in the US MUST decide to create, and conform to, a national standard not just of education and licensing, but standards and parameters of practice. Any woman attempting a UC should be outside the scope of that practice, since by definition a UC is not a low-risk birth, and midwives should be restricted to carefully defined low-risk patients only, except in hospital where they can work with medical backup.

December 1, 2012 | Unregistered CommenterAntigonos

This, of course, isn't the whole discussion that took place. However, my comment about the booster seat is to illustrate that we already legislate to keep children safe and that not everything in life is left up to the parent. Why should birth be any different? If the "battle" UCers are fighting is over choice, I think it's prudent to keep in mind that as a society we value the innocent and the "choices" they cannot not make for themselves. Therefore, we create laws when needed to protect those lives from negligence. And yes, UC IS negligent.

December 2, 2012 | Unregistered CommenterDJ

These sweeping, incendiary statements are exactly what make me nervous when these conversations come up. There are no studies of merit showing the safety or risk of planned unassisted births. I wish there were so we could line them up next to the risks associated with elective cesareans, a juxtoposition of the two birthing extremes. There is no conversation about qualifiers and individual circumstances. Has the mother in question has prenatal care? Has she had a baby before? What are her and her husband's level of knowledge and experience with birth and the related complications? Like it or not, women's reproductive health choices are all tied together. Legislating to make UC illegal is a short step away from making all home births illegal, and those have been proven to be safe, with qualifiers. UC is just another option a woman has. It is just as valid an option as any, even if it is not popular. As for doulas, wether they should or should not attend any specific birth is as individual as each birth is.

December 2, 2012 | Unregistered CommenterBJ

" the mother, who is merely an incubator"

WOW.

December 2, 2012 | Unregistered CommenterQoB

The question about what do I think about midwives being on call for women should they need help in labor... I don't think it's appropriate at all. Midwifery care entails months of care, months of getting to know clients and their medical backgrounds (despite people thinking birth isn't medical; it is), getting to know their styles of how they cope during stressful situations, etc.

To step into a situation with someone they didn't even know, into a complication they haven't even monitored into its creation is an amazing point of liability and, in my opinion, stupidity.

If a UC woman needs help, bloody transfer/transport. You're all about being on your own. Be on your own. You need help. Get help from someone who is used to sudden complications.

Even if all the woman needs is suturing, tough luck. Transfer. How unfair to drag a midwife into her drama of "I can do it all myself:" Well, then... do it all yourself. Suture yourself. Or transfer in.

December 2, 2012 | Registered CommenterNavelgazing Midwife

Being pro-choice and pro-autonomy, I find myself in the admittedly uncomfortable position of being pro-the right to UC. I think it is an incredibly dangerous and unwise choice, but I *do* think it is each woman's/family's choice dangerous and unwise choice to make.

As for a doula who chooses to attend a UC--I think it's a terrible idea on a number of levels. I think it gives an implicit "stamp of approval" to a terrible idea, as opposed to calling it out for the aberration it really is. I also think that a woman who asks a doula to attend her UC is remarkably selfish, asking basically, "Risk ruin to help me do what I want."

Fair or not, the real fact of the matter is that the majority of people are repelled by the idea of UC. There are *plenty* of individuals who will want to make an example if a UC goes wrong, and a doula in attendance is a likely target. For the doula it represents a tremendous personal/professional risk. If things go awry, the chances of prosecution/persecution seem awfully high.

Furthermore, if it does all go to hell and the doula is being hauled into court, I think I'm representative of a lot of people when I say I'm not going to wail and gnash my teeth at the unfairness of it all. Why? A number of reasons, not the least of which being that I think agreeing to attend demonstrates an astounding lack of judgment. Even if you personally believe UCing is a great choice, I wonder at the lack of self-preservation instinct that puts one in a position as the paid professional at a UC birth.

December 2, 2012 | Unregistered CommenterKate

To the commenter who did not like my reference to the mother as an incubator:
When there is a car accident, do you first take care of the car, or do you rescue the persons in it?
Are a mother's feelings more important than the life of her infant?

Of course, if a birth can be both safe and pleasant, that's the goal to be sought. But when one has to choose between warm, fuzzy feelings or indulging in behavior which is potentially dangerous to the baby or mother, or both, then there's no contest. I always am amazed at how easily the rights of the most helpless individual in this situation are consistently disregarded in preference to the wishes of the person who should be the MOST concerned about protecting her child. This is egotism anf selfishness on a massive scale.

December 3, 2012 | Unregistered CommenterAntigonos

Antigonos, if you think it's somehow illuminating to modify your analogy by comparing a woman-- excuse me, in your words-- HUMAN BEING-- to a *different* inanimate machine, then I'm pretty sure you don't understand the objection to it.

December 4, 2012 | Unregistered CommenterBuko

As a doula trainer, this topic is taking up more and more time with every workshop I teach.

I am 100% pro-choice when it comes to birth. I can disagree with the choices a woman is making and I can support her as a doula...I do this all of the time when a woman opts for things she said she didn't want just weeks before. But when I do this as a doula working with a woman who has a care provider, I am not putting myself at risk of being arrested or sued. UC is a whole different story. There is no medical professional. There is the woman, her partner (maybe), and the birth doula who has the most knowledge about birth of all of the people there. If something goes wrong, and things can go wrong in even the most peaceful and unhindered of births, it will be the doula who is blamed.

One of the posters from FB, ASM, said:

"Until then, I take my risk at jail time for serving UC's as a doula. Because I serve women. And I accept risks for what is right for her. But that is my choice and mine alone. And I don't give a flip what anyways else says. Women deserve a choice."

I am really hoping that ASM is a single woman with no children at home if she's willing to take this risk. If she's not, she's not the only one taking this risk. She's asking her partner and her kids to be ok with her going to jail for a woman they've never met. And frankly, every doula who attends a UC is taking this risk. What message does this send to your family? This woman's choices are more important than you having a mother in your life?

On a side note, there are two "professional" terms being thrown around: birth professional and medical professional. I agree that doulas are not medical professionals. We do not, or at least are not supposed to, do anything medical. I take issue with folk saying I'm not a birth professional.

I have worked hard to be the doula I am. I have taken workshops, gone to conferences, I read research, and talk with care providers about doula support. I have worked hard to become a Lamaze Certified Childbirth Educator, having to write my own evidence based curriculum. I worked hard to become an approved doula trainer with my certifying body, again writing my own evidence based workshop curriculum. I am constantly reviewing my classes and identifying areas that need revamped and finding a better way to teach different topics. I take continuing education workshops on communication so I can learn how to better work with doctors, midwives, and nurses. Because of this, I have a great relationship with many doctors, midwives and nurses in my community. I've even bumped into a few nurses at the grocery and they remember me...they remember my name. I've had nurses, who initially were not happy I was there (and I 100% understand why), pull me aside later to thank me for being there.

I get my role as a doula and I understand the role of the medical professionals. I know I am not a medical professional and I'm good with that. I am, however, a birth professional. Do I think ALL doulas are birth professionals? Nope. I wish they were though.

December 6, 2012 | Unregistered CommenterCatie

I am gobsmacked at the references to cars and incubators. Seriously is that a wind up? Coming from a trained person that is simple disturbing.

December 9, 2012 | Unregistered CommenterJo

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