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Tuesday
Apr172012

Doulas & Advocacy

Patrice Nichole Byers of Birth Your Way wrote a great post entitled, “Doulas and Advocacy: Are they mutually exclusive?” In there she discusses the role of doulas and whether speaking out for the mother during birth is an appropriate thing to do or not.

“I hear time and time again. I'm sitting in an interview with potential clients and they tell me that one of the reasons they want to hire a doula is to have someone advocate for them in the birthing room. I'm constantly explaining to clients that while I do consider myself an advocate of choices in birth, natural birth, and natural postpartum choices; I do not advocate for you during birth, but rather help you to advocate for yourself.”

I’ve also heard women say they want someone to “advocate” for them in labor. What I’ve learned they really are saying is they want someone who will speak up for them so they don’t have to. When women are in the throes of labor, it’s understandable they don’t want to be the one to disagree with the nurse or doctor. How appealing to have someone else be the heavy, deflecting any of the negative energy that might be coming from the medical personnel, allowing the laboring woman more peace to work her birth.

But when a doula opens her mouth with “She doesn’t want that,” it all too often sounds like the doula is directing the labor, not the woman herself. Especially if the client is wrapped up in her labor and doesn’t affirm what the doula said, the doula really does begin digging a hole for herself, credibility falling precipitously into the chasm.

If the doula was only saying “She doesn’t want that,” it might not be so bad, but it’s far worse as Patrice continues:

“I'd hear over and over about stories of doulas who would get into heated conversations with doctors and nurses about hospital policy, clients wishes, evidence-based practices and more. I'd hear doulas brag about arguments they felt they won, shouting matching, standoffs, and more. The worst to me are the stories of doulas who unhooked IV's, stopped the pit machine, and spent time interpreting fetal monitor readouts.”

You’d think these rogue doulas are rare, but from talking to my nurse friends (who are extremely doula and natural birth friendly), they are not. Many doulas seem to see their role as adversarial instead of supportive. That attitude alone sets the client up for a negative experience. Not that it’s always bad, but cooperation works much better for women than hiring a body guard.

If a woman feels she needs a body guard, if she’s in a state with legal midwives and can find one with impeccable education and skills, she should look elsewhere to birth. (I know, that’s a lot of “ifs.”)

I don’t have a perfect answer for the women who do feel they need to hire someone to speak for them. Perhaps in their experience they aren’t very vocal in labor or they want to immerse themselves in Labor Land instead of remembering, as one woman recently said, to try to remember “intermittent monitoring, not continuous.” In these cases, I would say the burden falls onto the partner. I usually encourage the other parent to let go and be in labor, too, that they don’t need to stand guard over their wives, questioning every move the nurse makes, but perhaps there is a place for a Bradley course after all.

I’d love to hear what doulas and women have to say about this topic. Thoughts?

Reader Comments (12)

You make great points, but for me (as a doula) it goes beyond that.

I don't speak for clients because to do so removes *their* voices. It's all fine and good to set out plans prenatally and say that no matter what you're going to adhere to them, end of story. But as I doula I can never make an assumption that a mom has changed her mind. She should always be given the opportunity to use her own voice. I may say "Jane, we talked about this intervention prenatally and you indicated that you felt X way about it, do you still feel that way now? Do you have any questions about it at this time?" This allows the woman her voice. It takes me out of the equation. Besides, speaking for her takes away her power, it dis-empowers her. I don't empower clients, but I do try to help them discover and claim their own power. It's in there, sometimes we just need a little help finding it. So instead of speaking for my clients, I try to teach them how to communicate effectively for themselves. And of course encourage them to seek more compatible care whenever necessary.

I think that many doulas like for their clients to be DEpendent on them. It makes them feel good, bolsters their confidence. I also usually see those same doulas have a need to "fiddle with" labor all the time. They have a hard time simply holding the space. The longer I practice the more I find myself doing less. I don't need to fix what isn't broken. For those clients who haven't learned how to be independent my goal is to help them learn tools and skills to become independent. Once this baby is born our relationship will soon end, I want them to have the skills to make informed choices for the rest of their lives. I want them to know how to research on their own, how to identify sound research vs opinion or skewed information, how to work together towards a common goal. When it's all said and done I want them to feel that THEY did it together. Not "We couldn't have done it without you!"

April 17, 2012 | Unregistered CommenterDoula2you

I had a doula at my first two births (one at home, one in a hospital.) After the second I realized that I don't really need a doula. My husband is a fantastic support for me during labor and an excellent advocate for me at the hospital. By being involved in preparation (since I'm well informed, he has learned a lot from our discussions) and then in advocacy (as needed) and support, he takes a lot of ownership and pride in "our" births. He is the natural legal and cultural advocate. Plus because I love him there is a deep well of emotional support to draw from during labor. For us, labor is an intimate and romantic event, something we both look forward to. We haven't taken the Bradley classes but I do LOVE "Natural Birth the Bradley Way" as a perfect husband-birth-prep book.

April 17, 2012 | Unregistered CommenterVanessa

The time for doula advocacy is BEFORE you get into the labor room. I talk with my clients about what is important to them, encourage them to make sure their doctor/midwife and choice of birth location are good matches for their values and ideas about what will make for good care for them. We talk about informed consent, asking questions so you understand your doctor's suggestions, and the notion that it's okay to say, "I need some time to think about this," or, "If there's not a pressing medical concern, we would like to wait a few more days before we..."

My contract states that I will NOT speak for them, nor make medical decisions on their behalf when they are at the hospital. That doesn't mean that I would not speak up if I saw something I knew they didn't want about to happen, but I can only remind the couple of what they said was important to them. "You had this on your birth preferences. Is this still important to you, and if so, do you want to talk to the care provider more about it?"

Barb, I think you are right that if you buy the hospital ticket, you go for the hospital ride. People should realize that actually, the doula is the most impotent member of the care team in terms of power and medical decision-making. I am NOT gonna get in a fight with your doctor. Tension in the room doesn't serve anybody during labor, and you are paying me to help you feel calm and supported, not be a bulldog. I can interpret medicalese, encourage the woman and her labor supporter(s) to ask more questions or time to talk privately with their partner, and offer up whatever alternatives I know of that they could ask to discuss further. I will remind the partner to remind the doctor that they wanted delayed cord clamping, or mention to a nurse coming on shift that the couple's birth preferences are sitting on the counter, and could she please read them when she gets a minute? I will also ask the mother something like, "Do you feel like you have the hang of pushing, or do you still want the doctor to help guide you with perineal pressure for another contraction?" if I know the mom didn't want the doc's hands in her vagina while pushing. And I will ask the nurse, "Mom's been laying on her right side for 45 min. Could we rotate her to the left side for awhile now?" The hospital I mainly work at stresses how important it is for the doula, family, and nurse all to be communicating. The staff don't usually say no to requests for food, hydration, tub, etc., but they do like to be kept in the loop so they can monitor baby during position changes or know that mom is making a location change from tub to bed or whatever.

I believe that ultimately, birth is a time of transformation and growth for the mother and her partner and that they are the ones who have to do all the hard work of moving through this transition to being parents to this new baby. Sometimes part of that journey is about working with power structures, figuring out how to set boundaries and limits, getting in touch with the mama-bear who will protect her babe in the face of a threat, or making peace with trusting another person and allowing somebody else to make decisions for you. It can be a time of gaining fuller access to one's own inner strength, knowledge, and wisdom, and that can take diverse forms. Just as I cannot be the one to find the inner reserves within the woman in the throes of transition, I cannot bestow upon her the inner power she might need to advocate for herself. In both endeavors, I can coach, encourage, act as a mirror, but I cannot walk that mile for her. I do not presume to know before a birth what a mother will gain from it, but it feels supremely important to me that she owns the responsibility for decision-making from start to finish. And in fact, I would be taking something valuable away from that mama if I stepped in and did that work for her.

April 17, 2012 | Unregistered CommenterKatherine

Katherine: I should have had you write a Guest Post! That was awesome! LOVE what you said. You sound like a great doula.

April 17, 2012 | Registered CommenterNavelgazing Midwife

I am appalled by the idea of a doula unplugging IVs, turning off pit, etc, and can honestly say I've never encountered a doula who did such things (or heard of a doula doing these things from my peers). I just can't imagine. I really do dislike the half-veiled 'this is a departure from your birth plan, what do you think?' stuff i do hear doulas say and hear being advocated here. It sounds the same to me, but more undermining against the nurse/docs. Also, if a patient wants to change sides or positions, I ( as a nurse) encourage it! Most often if they are on central monitoring we can see baby go off the monitor and then go in to adjust the monitor. If they're on intermittent monitoring then it doesn't matter!

April 17, 2012 | Unregistered CommenterRM, RN

I want to add, that as a doula who has been a labor and delivery nurse, it goes both ways. When I walk into a hospital that makes me sign a waver saying I will basically not question the medical personal, that sets me on edge. It is a hard line to tow. I try really hard not to fight, but there are times when I ask questions about what they are doing. Part of the problem is that women don't even know they can ask questions.

Some nurses are great when I do this, but quite often they see it as a turf war.

Another question we should be asking is, why do women feel they need the doula as a advocate anyways? There is obviously something wrong when women feel they have to be protected. When I was in nursing school, nurses were taught they we were the patient advocates. That sometimes we had to stand up and speak up for the patients desires, best wishes and needs. This was considered acceptable. So why is not considered acceptable when a doula does the same thing. I do ask questions, I will point out to my patients that they are pulling out the amniotic hook if they have not said anything, I will ask if there are not alternatives if I know that that is what my client wanted.

On the otherhand, I try really hard not to take on the role of providing medical advice. I won't mess with iv's, efm etc even though I have the experience and know how. I often plead with my clients to discuss their intentions with their chosen medical providers.

As a nurse I was proud to be called a patient advocate, as a doula I feel the same way. But it is a tricky line to cross. Particularly when the two camps don't know or trust each other much. Because of this, I have really tired to reach out to the medical community and discuss how we can do things better.

April 17, 2012 | Unregistered CommenterRachel

I am work as an RN in a NICU. Recently I remember a doula coming to the NICU with a baby while he was being admitted. The family had originally planned a home birth but the baby was 34 weeks, with severe IUGR. Mom had had a c-section and dad was with mom in OR when baby came to NICU. When a baby of this gestation is admitted to the NICU we offer the baby a pacifier (often with sucrose) to help them trough the initial (and subsequent) painful procedures of lab draws and IV starts. This doula informed the staff that the parents did not want the baby to have a pacifier, which we honored and went ahead and did the procedures without the pacifier. Come to find out, once the parents we able to come to the NICU, that because the plan for the birth and baby had changed (premature/IUGR) their own plans became more fluid too. Of course they wanted their baby to have a pacifier to help him through the stressful times of his hospitalization. Of course they wanted him to do some non-nutritive sucking while he was getting his garage feedings. Of course they were willing to adapt their wishes (which were originally based on an assumption of a normal birth of a full term baby) to meet the needs of their son when his situation changed. I remember be so frustrated that the doula had ASSUMED the parents wishes and had not ADAPTED her beliefs to a new and different situation. She was not acting as an advocate for that baby or family by telling us he couldn't have a pacifier. It was such a small thing, to not let the baby have a pacifier, but it resonated big for me. This doula was unable to adapt herself to a new situation (preterm baby in the NICU) or to learn about how this changed the parents feelings and beliefs about what was best for their baby. The parents of course adapted beautifully to the situation and were thankful that their son was going to be okay and they were willing to change whatever they needed to to meet his needs. Too many doulas are so black and white in their belief system making them unable to adapt and meet their client's needs when the situation doesn't turn out the way it was planned. They think they are advocating but really they are pushing their own agenda without looking into what really is the best interest of their clients.

April 21, 2012 | Unregistered CommenterHeather

As a very new doula, I have found myself in some hard places. I live in small, rural town where most nurses and OBs not only don't know what a doula is, but are VERY resistant to having one present. While I want to form a working relationship with the medical staff, I also want to be able to help my clients speak up. The problem is that the nurses (mostly) seem bent on undermining my relationship with my clients. I have been pushed out of a room during an epidural placement with the admonishment from the nurse that I am NOT needed and I am NOT family. This was so hard because my client asked very clearly for me to stay, but we were both hushed. How in the world do you handle situations where you are trying so hard not to be combative, but it's obvious that your client's wishes are NOT being heard?
I have come to feel very defensive over the last year and a half. I feel very strongly that no matter what it is that my clients want, they should most definitely, at the very least, be heard. As a doula, should I just stand by when a mom's able to use her voice but is simply ignored? Where do you draw the line? I am struggling to find a place in my community, but I am honestly the ONLY doula in a 60 mile radius. If any more experienced doulas have advice, I would be thankful for it.

May 3, 2012 | Unregistered CommenterPennie

Pennie-
I know exactly how you feel. There is a lot of hostility on both sides of these equation. I have made sure that I always meet with my clients doctors beforehand. I visit the hospital beforehand and talk with the nurses as much as I can. I have called the managers and discuss with them some problems I've had as well as what I have liked. I always make sure I send in thank-yous when I feel like they have done something well.

One thing that was telling, though, was when I was talking about a particular problem I had one time with a nurse. I called her nurse manager to discuss how we could resolve this. One of her nurses told me to quit taking care of "her" patient. The manager then explained, "well, you know how nurses are, they are territorial."

I have also worked as a labor and delivery nurse, so I know the territory:) We don't like people telling us what to do or how to do our job. Doulas are fairly new and will take some time to become established as a normal part of a woman's birth team. I always encourage women to let their nurses and doctors know that they desire that. I also encourage doulas to make the effort to get to know the medical professionals in the area, and that if there are problems or issues to discuss it with them after the birth in a civil manner. The more doulas and health care professionals talk to each other face to face about the difficulties and good things about working with each other, the better.

May 4, 2012 | Unregistered CommenterRachel

Pennie: Welcome to the Doula Sisterhood. It's lovely, but hard-ass work as you're learning.

I haven't been permitted into an epidural but once in the last 10+ years and that was my daughter's. Unless the family member leaves, the doula doesn't go in... that's pretty much across the board. Sure, the doula would do wonders for helping mom feel better during the placement, but (sadly) rules are rules and it has a lot to do with making sure no one watches the procedure and inadvertantly takes pictures.

If you're able to prepare your client with the reality that you will most likely not be able to stay, they will at least have that information. I tell my clients I will be right outside the door or, if they don't let me stand there, right in the waiting room and will come back the second I am allowed.

I take that opportunity to run to the bathroom and grab something to eat. Even with fast anesthesiologists, you have at least 15 minutes or so. If you bring your own food, MAKE SURE TO GRAB IT BEFORE YOU WALK OUT! How many times I've forgotten my bag, phone, food inside the room. Aargh!!

I can't imagine how difficult it must be for you, being the only doula in such a huge area. Where in the world do you live that there aren't doulas? I didn't know there *was* still a place like that!

So, how do you work with staff that's not listening to mom. Great question. "Did you say you wanted me to stay?" "Did you say you wanted to get up and walk around?" That's probably the best start... repeating what she says, but letting her repeat it.

Isn't it sad this is an issue?

You ask "Where do you draw the line?" It's important to remember staff can kick your butt out if you get too annoying (in their eyes), so weighing being there vs. standing your ground and being booted out is where you have to go in your mind. How far can you push? Can you find even one ally?

Before you go in, some doulas have found asking for a nurse who's very natural-birth-oriented helpful. I don't know if you call in for your clients, but that's something you might do, too.

I hope some of these help, Pennie... and I hope you have much more pleasant births as time passes. Much good-luck.

May 4, 2012 | Registered CommenterNavelgazing Midwife

Thanks so much for the helpful ideas!
I have been trying very hard to get to know the local OB/Midwife community. It's hard and frustrating...but, I have seen a very welcoming response from the office staff that I have encountered. So, that's a step in the right direction.
But, then on the other hand, my local hospital refused me a tour of the facilities because I wasn't a potential patient. Seriously. So, I had to go with one of my clients when she went in for her tour. I try my best to be friendly and appreciative of all the work that I know the L&D nurses do.
I suppose, it is just a long road to travel.
I live in Ohio, right in the middle of Cleveland and Columbus. While both of those cities are pretty progressive and have SO many opportunities for natural birth, doulas, midwives, holistic care, etc., sadly, I am about an hour to two hours from each.(in good traffic conditions and fair weather.) The closest home birth midwife is about an hour away and she has stated that my counties are not really "her area". I LOVE this work, and I feel it is vital in this community. There is such a huge need for real education and support. Especially when almost all of my clients have been under the age of 25, with little to no resources.
I guess, I will just keep killing them with kindness. It will wear them down eventually, right?
On a side note, I had a conversation with one of the nurses after my last birth while we were in the elevator going home. I asked her if they worked with many doulas, or at all, and how she felt about me being there. She was tired, but semi-friendly, and told me that she had NEVER worked with one, and that she thought one of the other nurses had looked into certification at some point, but she had decided against it because "women around here just don't want one". Sigh....

May 4, 2012 | Unregistered CommenterPennie

Barb,
Just soothing myself on your blog as I get closer to attending my first birth as a new doula. Some how I ended up reading the recent NY Times piece from a woman who talks to Ina May Gaskin and then details her birth narrative. The snarling and anecdotal dirt-throwing polarity party in the comments, I just make myself sick reading there. I mean I know better than to read that stuff but I did it anyway! I try to take refuge in my sex educator training: suspend judgment, remember evidence-based...

I found your blog in Jan. after my doula trainer off-handedly mentioned Dr. Amy, into whom I of course got time-sucked and some how landed here, devouring your writing, your journey, your realistic-ness. I loved wrapping around the concept of having such limited knowledge as to be unaware that one doesn't know what one doesn't know. Anyway.

I've accompanied to the hospital twice before. Once for a rape kit as a trained "advocate" (I mostly witnessed) and once for a friend as a friend. When I was in the hospital w/my friend, my role was hangout comfort support buddy and mirror, and it seemed to help all parties involved. I want to bring that with my doula presence. I get the sense that humility and 'this is not about me' are also valuable to bring along.

I'm obvs just beginning my journey and am curious to grow in how I contribute before the labor room. And I really appreciate Katherine's input.

Pennie,
My family home is just north of Canton. I'm all the way out in the San Francisco area for the foreseeable near future and am often prattling on about how I want to bring the tools I'm picking up out here back to OH when I'm ready (I am so not ready!). Big respect to you for being and doing this crucial work between Cleveland and Columbus. My e-mail is emily at fortunatelythisisaloveletter dot com if you ever want to be in touch for some Ohioan support.

May 24, 2012 | Unregistered CommenterEmily

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