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Thursday
Aug092012

A Doula's Role?

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?

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Reader Comments (12)

I consider myself extremely fortunate. My DH was my untrained instictual doula. He sat by my side during labor basically shooing away any hospital personnel until the time to push.
He was respected and never second guessed by the nurses, he sat by calmly telling the staff,'leave her alone. She doesn't want to be touched."
My hero!

August 9, 2012 | Unregistered Commenteresthervegan

Although I've only been a professional doula for a short while, I have learned from experience and teaching that a doula isn't meant to be a hot-headed bodyguard. Rather, we are meant to help the mother and her partner not to lose sight of their intentions and wants during the excitement of labor and birth. A partner is extremely valuable and i think the Bradley method is a great option. Still, i know that there are times when one partner isn't the best at calming the other (or may not be availabke or present at all) and a neutral third party, such as a doula, can provide enough emotional distance, but warmth, to minimize potential stressors for both. I respect the work that all healthcare providers do and always conduct myself in a professional, respectful manner. As in all professions, everyone may not do the same, but I believe there is much value in a doula.

August 9, 2012 | Unregistered CommenterDannelle Simon

I really emphasize this over & over in interviews and prenatals. I work out code words or phrases with them that alerts them that they have an option they might not be aware of, or to let the partner know it's time to speak up. And as tactfully as possible, I try to get across that you buy the hospital ticket, you go for the hospital ride. I agree that if you truly do not want to have to advocate for your wishes, you need to find a care provider that will honor them without question, or practices that way already. For many natural birth minded moms that is homebirth or birth center only. We are in a tough situation here where those options are limited and/or so overbooked that they are often inaccessible if you decide during pregnancy that you want to transfer, but it's worth a try.

There are so many times that I feel adversarial...of course I don't act on it because I am a professional. But after experiences of seeing the parents change their minds in labor and go with interventions they said they were opposed to, I also realize that I would be setting myself up in opposition to clients much of the time. They have to live with their decisions, not me. Still, you have those moments that haunt you...real abuse or malpractice...you wonder if you should have said something.

A lot of partners cant/won't speak up for their wives either. They feel cowed by authority, or they believe in it, or they fall for appeals about protecting their wives from pain, or they are coopted by a male to male thing with the doctor about the irrationality of women at "times like this."

As we all know, there are not always good alternatives for women. But some places have free standing birthing centers run by CNM's; my second daughter, Emily, was very happy with two births in one. Some places have CNMs doing home births.

If there are no good alternatives, can't a doula at least ask to speak to her client before a decision is made, and remind her what she said ahead of time about what she did and did not want? Then she can at least say to the doctor, my client tells me she does not want X. I think the mother must at least be able to say "no" for herself. And we know this won't always be effective, no matter who says what.

Perhaps a friend with the same ideas about birth as the mother, as long as that friend and the husband are really comfortable with each other, otherwise the husband's capitulation to the doctor will completely marginalize the friend. Whoever is going to be there, I wonder if play acting various scenarios ahead of time (there is a better word for this but I can't think of it) could help the woman and those present with her to have the presence of mind to know what to say at that time. Of course, not all scenarios can be anticipated. And this kind of awareness is not entirely compatible with being in labor land. But we are talking about making the best of an imperfect situation.

Of course the best answer is for there to be lots and lots of well trained midwives for home births and birthing centers, and to handle those truly more difficult/risky births in hospitals under the supervision of OB's.

And until this is the case some women will find their own answer to their immediate problem with the best midwife they know how to find, or even by giving birth with only the support of friends or spouse, no matter what anyone says about this. As I did.

Susan Peterson

PS I know some husbands are strong advocates, but this was not my personal experience. Although my husband was supportive to me, he didn't really grasp what it was that I needed at the crucial times. Even with a class meant to prepare them to be advocates, I don't think every man is ever going to have the interest to learn this subject well enough to feel that he knows what he is talking about well enough to oppose someone pushing hospital policies or trying to scare him. I don't think every man is ever going to have the personality to oppose authority in an assertive but not aggressive way. I really don't mean to be putting down men. I just think the role of advocate in birth is an unreasonable expectation to have of all men, even of all good men who love their wives/girlfriends/partners.

August 10, 2012 | Unregistered CommenterSusan Peterson

I would never speak for a woman in labor as a doula even if the woman wanted me to. I make it clear I don't speak for them but remind them of informed consent and it's their job to speak up or their partners. I find it out of my scope to tell a nurse or doctor what my client wants. I remind my client of their wishes when a decision has to be made regarding interventions ( that aren't emergencies) and leave it in their hands. At my first birth the pushing stage was being directed by the nurse ( even though the woman was not medicated ) and I reminded her to take two breaths inbetween pushes instead of one ( one for you, one for the baby. That's what we were taught at training) and the nurse kept telling her only one breath and PUUUUSSHH!!! 1-2-3-4-5-6-7-8-9-10! ( ridiculous) after a few attempts i gave up because it wouldn't have made for a peaceful environment. The woman ended up with an oxygen mask ( which could have happened anyway but you never know). As a doula I find keeping a peaceful environment is key, arguing with staff is counter productive to a positive birth experience in my book.

August 10, 2012 | Unregistered CommenterTara

As a doula, the term "advocate" is often one of the first things I clarify that I am not, in my meetings with couples. I help couples advocate for themselves. This is primarily done by giving them lots of information beforehand, letting them know what to expect in the hospital, the common interventions that they might be faced with, etc. I help my clients to ask the right questions of their medical team in order to be able to make a fully informed decision.

Sometimes a couple will be overwhelmed or forget their preferences when the doctor is pressuring or suggesting something. If that happens, sometimes I suggest a question to ask, according to what I know their birth wishes were. Such as, “You expressed concern before about x intervention. Did you have any questions for the doctor specifically about what he/she is recommending, or about how x might affect x?” This is said in a respectful way, right in front of the doctor or nurse. Or sometimes I say, "Do you feel you’d like to ask for a few minutes to think about this?" and that often gets everyone to give them some space or time to consider things. If a couple is looking to me for my "recommendation" at this point, I'm verrrrrrry careful not to contradict the doctors, and like to turn it around and ask questions of the couple. “How do you feel about the suggestion?” If they really aren’t comfortable with it, “ Do you want to ask about alternatives or a delay?” And of course reminding them that if mom or baby are not at risk, then negotiation is possible. This is their birth. The medical system is based on informed consent, and yet clients don’t always get all the information (or options) that are a possibility.

Sometimes I'm dying to say something when I see medical staff dodging questions or seriously glossing over the facts, but it’s not my job to intervene or contradict. It’s a fine line to walk—making sure that clients get all the information, while not making it an “us versus them” feel. The job of a doula requires a lot of creativity in regards to communication and interaction. I try to keep a smile on my face and positive energy in the birth room. Maybe some doulas would take a more aggressive stance to protect their client, and they might change something about that one birth. But are they doing doulas and the women who need them a disservice in the long run by creating animosity between doctors/nurses and doulas? It can take quite a while for the medical staff to warm again to doulas after encountering a “rogue” one.

August 12, 2012 | Unregistered CommenterCynthia

Cynthia: Very well said!

August 13, 2012 | Registered CommenterNavelgazing Midwife

This is a difficult topic to me as someone who seems unable to verbalize practically anything during birth let alone make a decision. I probably said 5 phrases total during labor this last time (unmedicated VBAC). My friend who acted as my doula and husband would ask for instance if I wanted to get on the bed or continue to stand. I seemed completely unable to answer or even concentrate on what I might want. I was lucky to push out the words "I don't know". So hard to concentrate on anything external.. So on the one hand I think its kind of ridiculous to assume that all women are going to be able to advocate for themselves in the middle of all that.

But I also totally agree that doulas should not be put in a place where they need to be loudly advocate for their clients or speak for them. Definitely seems inappropriate in most circumstances and like it would lead to bitter relationships between hospital staff and doulas. I guess the only solution is for the spouse or other family member to speak up if need be. I also like Cynthia's suggestions for how to rephrase things to allow the mom or couple to talk or give them more space to assert their choices.

Definitely not easy....I can't imagine being a doula

August 15, 2012 | Unregistered CommenterMargaret

As a DONA certified doula, I had to sign a "scope of practice" document and I am not even allowed to speak for my clients even if I wanted to (I don't). Additionally, the hospital where I most often work has me sign a one-page document every.single.time that lists in detail what I am allowed to do (provide praise, support and encouragement, provide a calm room atmosphere, encourage ambulation and position changes, provide comfort measures, offer ice chips, etc.) and what I am not allowed to do (adjust medications or IV infusions, perform vaginal exams or perineal massage, interpret FHR tracings, etc. etc.).

August 18, 2012 | Unregistered CommenterAnna

I think it's so hard to know in advance what you'll actually need on the day. So keep an open mind.

My sister, for example, watched a show on women birthing at hospital and hated the cheer leader tone of voice the midwives seem to take with all the women: "you're doing wonderfully", "you're nearly there", etc. But when she actually gave birth she forgot to ask the midwive to talk to her like an adult, got the cheerleader act and loved it. She sait that after having had contractions for 8 hours, you do want someone to tell you how wonderfully well you're managing. It does help.

I had carefully trained my husband on what I wanted so that he could help me when the time came (IV's, monitoring, being able to move around etc). In fact, when the time came for my first baby, I hardly had enough time to get to the hospital birthing room, let alone be monitored. It wasn't something that any of us had anticipated. I remember the nurse running to the room pushing me in a wheelhchair. Nothing was ready and the baby nearly fell out onto the floor (well, nearly).

So my thought for the day is, think camly about what you would like in an ideal world, and then keep an open mind on the day. There will be YOU , in the midst of contractions and no two births are the same. There will be the BABY (and some of them do weird things on the way down that change how you can birth. My second baby needed a bit of help as he decided to come down like superman: fist first!). There will be the midwife/doctor/nurse with their different levels of training skills, experience and tiredness (I found giving birth at 4 am meant I had ONE very sleepy midwife whereas my 6 pm birth meant there was a gaggle of hospital students all trying to be sympathetic and pat my hand! I prefered the 4 am one).

So KEEP AN OPEN MIND. You never know what might happen.

I'm not sure it helps to ask to birth at a place AND take someone whose role is going to be to try and stop them doing their work. It seems to me it would be better to try and discuss the issues WITH them before.

August 20, 2012 | Unregistered CommenterLeah

Well, my transitions always felt like I was about to drown in water - hardly came to the surface and if so, I had to take a deep breath in order to last with that for the next long dive. That was for about 2 hours each of my 3 births, means: I COULD NOT SPEAK!!! And yes, either you read my thoughts, or know what I want or don't want. For THAT I thought I need a doula.

September 9, 2012 | Unregistered CommenterHeidi

I have faced some pretty icky situations where I had to set my feelings/opinions aside, but as a doula, I seem to have the best luck advocating by asking questions with both care provider and client present to clarify what the doctor or nurse is suggesting to the client, encouraging conversation between them so that I am not the focus of this discussion, but I can at the same time remind the mother she needs to speak up for herself and remind the care provider that the client isn't necessarily okay with any procedure.

October 8, 2012 | Unregistered CommenterNaomi

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