Modern Doula Care

As doulas, we go on a significant amount of interviews. The interviews can take place at a coffee shop, the clients home, our office or even a mall or park. The location may be diverse, but the questions seem to inevitably be the same.  As experienced doulas, we try to give an overview of our services and experience and cover the questions that we know are running though a potential client’s mind. We hope, by the end of our conversation, the client’s neatly typed up questions or ones printed from the internet have been answered in a much more casual and comforting way.

But, what should you be asking that maybe the internet doesn’t even know about? Sure, certification is a good place to start. Number of births attended, although this one is subjective in many ways and doesn’t necessarily indicate whether a doula is skilled or even ‘good’, and finally, the fees.  There are other important, almost deal breaker items that don’t seem to be listed on the pregnancy forums.

The hard questions which should be asked are not about quantity of births, certifications, birthplace experience or even what ‘tools’ are in their birth bag. It can be business practices alone which can be the most important to an expectant couple.

“So, what happens if I labor for a really long time? Over 24 hours? Does your fee change? Do you leave? Do you share shifts like the nurses? is there continuity in care?” 

For many DONA certified doulas, continuous labor support means just that…continuous. Your present for active labor.  As a business owner, we have to manage the long labors and the short labors in our own business plan, but the continuity of care should not be broken because of the need for business profit. We are running a business, but let’s face it, the woman whose labor just hit the 24 hour mark isn’t exactly excited about being the woman who is making you work overtime and, quite frankly, may be the woman who needs doula support more than others.

Some doulas do have clauses to switch out or charge extra after a certain amount of time. Ask this question. Think about the answer. Mull it over. You may be comfortable with the risk and feel like overtime pay is appropriate. You may not. It’s a question that needs to be asked to avoid last minute feelings of resentment.  Let the doulas, who run their own small businesses, handle the details of their profit margin. As the expectant family, be comfortable with your choice of support and budget in any situation that may arise. In our practice, we don’t feel that a woman should be charged for a long labor simply because we need to cover our expenses for being at work longer than expected.  We don’t  believe we handle this issue the only right’ way, but we are comfortable with our business practice.

When do you come to me in labor?

Labor is unique. I have yet to attend two births that are exactly the same in the way labor begins, how a woman reacts, or even how quickly it progresses. As experienced doulas, we can typically tell from the ‘birth song’ of a woman through contractions or the partner’s voice on the phone and description of the laboring mother where they are in the stages of labor. If a doula’s business practice is that they arrive during early labor and stay throughout the birth and after or whether they come to you during active labor (4-5min apart contractions), is an important question to ask and feel comfortable with the answer.  You need to feel supported during your labor. Doulas are, by definition, servants to laboring women. Feel comfortable with the answer.

Can I meet your backup? Do you have backup? What are you plans for my birth window as of now?

Many women ask the question, “how many clients do you take a month?”. While this is an important question to gauge how busy a doula may potentially be, it doesn’t gauge what will happen if, by chance, those 2 or 3 clients go on the same day. Collisions happen. Not often, and in doula collectives or partnerships, they are handled much easier. Whether you take 6 clients a month solo or 2, mother nature sometimes just throws a doula a curveball.  So, as a client, you need to know the game plan. What if it happens? Will I know the doula who walks through the door? Will they have the same pieces of experience or philosophy that you have that I feel comfortable with? Meet the backups. Talk to the backups. Even if a doula has never used a backup, there is always a first time.  And most importantly, ask about your birth window. Even through we try not to, we tend to look at a first time mom and think, well, she will probably go a little overdue since that is extremely common. Do we plan vacations on your due date? Of course not! But, ask a potential doula anyway. They may not have the same business practices.

What Else?

There are many more questions that can be asked. Philosophy, connection, the all important feelings of ‘clicking’, but business practices and the details of the contract you sign will definitely matter when the first contraction strikes. Make sure you understand the way your doula handles her business and the protocol for a laboring woman.  We all do things differently, and that’s the great part of being a doula business owner. Connecting and supporting women with clear cut expectations of our roles in their birth village is an amazing job.  What better way to spend the day than to welcome a new baby earthside……

This week is “World Doula Week”. In celebration, I have a client a week overdue and was honored to attend a wonderful, textbook labor for another client who was first time mother.
I love being a doula. Being a doula means supporting a woman who is just “d-o-n-e” with pregnancy and understanding from personal experience as well as professional experience the heartache of postdate pregnancy. It is also giving balanced advice regarding the current research about induction without mixing in personal or past client experiences in the conversation.
The role of a doula is many times seen as the woman in the birth pictures leaning behind a laboring mother. Maybe rubbing her back or doing the favorite, “double hip squeeze”,  which is the go-to move for all doulas supporting a client. Being a doula is so much more.
We are birthworkers. Women with experience with local careproviders and birthplaces. We know so much more than the “double hip squeeze”. We know the risks and benefits of induction when you are postdate in a pregnancy. Maybe we even know the risks catered to your personal careprovider, if we have been a doula long enough in the area. We also have a pretty limited scope of practice that we agree to with our certifications. A doula isn’t a medical professional. We aren’t allowed to give medical advice or direction. We can support and guide a woman to make her own decisions, but we have balance our own inner voice. An inner voice which may be shouting, “Stay home!” when a client insists she must go to the hospital upon membrane rupture because her doctor told her that she must. It is almost as though she has seen an episode of ER and believes that once your water breaks, the baby is just two commercial breaks away.
In the doula world, a rift has been building as doulas strategize on ways to validate the role of the doula in the birthplace. As the role of the doula becomes more widely accepted or mainstream, the rift grows amongst doulas on how to represent ourselves and our role and how to run our businesses accordingly. No longer being hired by only rich or crunchy expecting families, doulas are being hired by average expecting couples who want a guide to help navigate the hospital experience. Doulas need to adjust their mindset and professional path to meet this demand and to define our role.

Although some define their value by hourly wage or by the goal of running a small business aimed at higher income clients, there are still doulas who see their role as invaluable  support. The support of a mother and father through their birth experience cannot be quantified by an hourly wage. Doulas need to be fairly compensated. We deserve to support our families with a decent living wage for our professional  services, just as any working professional. The rift is based on the philosophy that this value or living wage is the only reason why we are birthworkers and the only way to be compensated is by money or profit.

For “World Doula Week”, I am wishing for another perfect textbook labor for my postdate mama who is ready to meet her baby. I am hoping for the worth and value of the doula role to become as mainstream as the belief that when your water breaks, you must go to the hospital immediately. I am also hoping for the doula community to come together as one in order to solidify our role as valid members of the birth community.

I am hoping that the rift between doula sisters regarding fair wage and how to run our businesses fades and we realize that we are invaluable to the clients we represent. Our worth as professionals is not defined by our profit margin. Our worth as birthworkers is defined by the incredible work that we have chosen to do as a profession and the gratitude and respect of the families we support.  Whether they pay us well to show their gratitude and respect with money or with karma, as small business owners, it is our choice to balance our budgets however we choose. I hope as we end the week, we can embrace our fellow doulas and their philosophies and decisions just as easily as we hope that hospitals, ob/gyns, nursing staff and the average expecting couple embraces our presence and support that we provide.

It’s easy as a doula to migrate towards the world of homebirths and birth center births. As doulas, we tend to love the serene, comfortable setting of a birth center birth. The birth is treated as a normal physiological process and not something to be medically managed. It’s a beautiful experience where the doula is accepted as part of the birth village without question.

Hospital births may not be the same experience. The beeping machines, the continuous monitor belts that are  always seemingly tethers to a bed, I.v lines and nurses who are constantly in and out of the room typing charts into a computer. Absent are the dim lights and  the aqua doula tubs.  Women are told that contractions are to be feared and medications are available. Doctors are not necessarily fans of a birth village and definitely not fans of doulas  who advocate for alternative options to standard hospital procedures, let alone informed consent for standard ob procedures.

It’s these births where doulas can make a difference. A true and definitive difference. Bridging the communication gap between a new nurse who is confused about the importance of skin to skin, let around nursing in the first hour after birth, or just a gentle smile and words of respect to a doctor who isn’t thrilled with your presence or your reminder that AROM is a procedure in which the patient deserves informed consent.  It’s this doctor who may bring this experience into his next birth knowing you weren’t a hippie crazy doula. You were a  rational, well educated, professional doula and part of the birth team, there to support her client, and hopefully make birth normal.

Even though, as doulas, we need a birth center birth to revive us after a few rounds of hospital advocacy births, our skills are challenged and grow the most in a hospital setting. We learn how to mediate and graciously offer alternative to standard practice. We gain the respect of doctors by showing them our knowledge of birth and also by showing them respect for their knowledge. We humble ourselves to realize although we are birth professionals and valid members of the birth team, we are not doctors, midwives or nurses. We are doulas. We make birth normal by serving and supporting our clients well in any setting.

I’m a doula. In 2007 when I became a doula, I usually had to begin a conversation with another person about what I do for a living with helping them pronounce the word, “Doula” and then go into a ten minute narrative explaining what exactly a doula does. The inevitable remark of, “Isn’t that what a friend would do?” or my favorite, “That’s  what the nurses do, right?” would happen next along with a smile and nod. Now, fast forward a few years and in 2015, most expectant parents know what a doula is and are discussing if they feel they need one for their birth.

Doulas have slowly become accepted in most hospital and birth centers as a valid member of the birth support team. Even the doctors, who would rather not have to deviate from their comfortable work patterns and their own birth script and plan for their patients, have realized that their patients are choosing doula support and are expecting the doctors and nurses to be respectful of their choice.

Birth has changed. Our healthcare system and careproviders, for years, have dictated the script of labor and birth. With rigid time limits, invasive procedures and a culture of medical management, the modern birth didn’t shape up to be exactly as enlightened as one would  have hoped.  Continuous monitoring was introduced, epidurals replaced spinal blocks and forceps, mothers were allowed to walk around during labor instead of being in bed, but, still our c-section rates rose and our births were becoming more medically managed.

In 1999, women were signing up for inductions at 36 weeks and scheduling their surgeries to avoid stretchmarks with little regard to the effect of premature delivery or the risks of major surgery. We had changed and modernized birth, but we didn’t necessarily make it better. We definitely hadn’t made it appear, “normal”.

Doulas are helping expectant parents edit this script. Somewhere in the last decade, we have begun the process of wading through the managed care of pregnancy and birth and start to push back on the limits and rigid standards of what the medical community deems the textbook labor. Women are realizing that maybe technology and birth don’t exactly need to go hand in hand. Maybe, just being low tech is better.

As a doula, I feel my number one commitment to a family is not that they get the perfect birth, but that they get an informed and empowered birth. I help normalize the experience and not medicalize birth.  I am not a doctor. I have no time limits on how long I will hold your hand, apply counterpressure to your back during a contraction or help position you to turn your baby to lessen your backpain.

Modern birth is shaped by computers and medical charting that needs to be completed every hour. The ticking and beeping of the fetal heart monitor and the contraction monitor as well as the endless questions regarding health background information and consent forms to be signed that can be the last thing a woman wants to do in the middle of labor. Modern birth is a doctor coming in every two to four hours just to do a vaginal exam, shake his head or nod depending on the assessment and then leave for the call room until pushing time. Although a family may have a wonderful bond with their doctor and love their hospital, the reality of the typical birth experience is much different than they anticipate. Modern birth is anything but normal.

Doulas keep the woman the center of the birth. We keep the family and the birth the focus.  After attending over a hundred births, I have seen many birth scripts, not one has been the same as another. My goal is never to have a woman go without pain management or for her to treat her birth as the pinnacle experience of her life. My goal is to keep her birth normal. Normal. Not modern, not crunchy, not exceptional, just normal.

Birth is normal.  I guide women through early labor so  we don’t arrive at the hospital and end up on the “labor clock” too early. I  assure them that bleeding is normal and if your water breaks, it isn’t an emergency. “You are safe, you are in labor, you are going to be a mother soon, and your body will work. You are normal.”

Preparing a mother for a normal birth is incredibly important. Knowing you can rest, eat, walk, shower and even sleep in early labor will decrease a chance of a c-section. Staying home until active labor is an amazing feat in the modern birth. Having a support person who can safely assess when to leave for the birthplace according to the mother’s plan, can shorten the stay at the birthplace and lower intervention.

Doulas often get the reputation of being defiant, anti-medical, anti-doctor type super feministic women who charge into the hospital with our patchouli and peanut balls just waiting to jump in front of a doctor with an amnio hook. That’s not my idea of a doula and it isn’t the doula that I am.

Once doulas begin to realize that we are there to create a normal birth and not an exceptional one, maybe we can better fit into the labor and delivery room with a doctor who is trying to represent himself as the super human baby catcher. Families are hiring doulas to have a guide through labor and to avoid unnecessary interventions in a modern birth full of ways to intervene. Doctors have become amazing surgeons who can safely deliver babies in distress. Midwives have become supported team mates in collaborative care of women in hospital settings. Now, it’s time for doulas to become the final piece of the support team. The one that guides the woman through the normalcy of labor and empowers her to make the choices in her labor that make her feel comfortable.

We are not being hired to create the ultimate birth experience. That job, I wouldn’t even want to take. Birth is unpredictable and doctors and midwives have an enormous responsibility to bring mother and baby through it healthy and happy. Doulas, well, we just get to to make it appear normal.

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