Did you hear the one about the pregnant woman who was discouraged by her obstetrician from hiring a doula? It’s not a joke, not folklore, and the stories of distrust or even confrontation between hospital staff and doulas is also not new. As knowledge of and about doulas has increased in the last few decades, many couples will continue to have a discussion with their practitioners about whether or not to hire a doula, also known as a “labor assistant” or “monitrice.”
A quick search on the internet of “obs against doulas” yields numerous hits. Some very confused mothers write into listservs questioning why their doctors would discourage them from having an advocate in the labor room. Some very passionate mothers and/or birth advocates respond that the confused mothers should change obstetricians or find a midwife. They recommend that they find a doctor more accepting of patients’ choices and ultimately welcome the doula into the delivery room. Sometimes, however, a change in medical practitioners, especially late in pregnancy is impossible. Let’s imagine a discussion between an expecting couple and their ob, explore the reasons why a medical practitioner might discourage a couple from using a doula, the potential implications of this recommendation, and ultimately, the benefits of hiring a doula.
I can envision how this topic might come up during a prenatal appointment. The pregnant woman and her partner, having done their homework, and possibly also having taken a childbirth class, ask their doctor, “do we need a doula?” Let’s imagine that we’re still in the middle of a recession and that this is a first pregnancy. Our pregnant mama has had to weigh many factors as she and her partner prepare themselves for the birth of their baby. She may be concerned about the idea that hiring a doula is an extravagance (especially in this economy.) She may have already spent too much money getting ready for the baby, because this is, after all, a consumer driven economy where the acquisition of things rather than services dominates many of our decisions, even those that involve how we give birth—but I digress. She asks herself if a doula could possibly be an unnecessary expense in the long run. She may be interested in having a natural labor, or she may want to remain flexible in case she opts for using medication. She may not want to feel pressured by someone who she perceives to be only a natural birth advocate. She asks herself if the ob practice that she’s hired and the nurses on staff at the hospital won’t be sufficient to help her and her partner to achieve the best birth possible.
The doctor, on the other hand, may have had varied experiences (or none at all) with doulas at the hospital. He or she may have heard negative stories about doulas from other medical staff, or fears in general that having a doula present would interfere with their ability to perform their job. They may feel uncertain if they would be able to communicate effectively with their patients, especially if a medical decision needs to be made. In this scenario, the doctor assures the patients that the doctor on call will help them to achieve their goal: “a safe and healthy baby,” and that hiring a doula is unnecessary.
Let us imagine that our couple has a longer than average labor. Our mama has decided to provide her ob with statistics and other information about the benefits of hiring doulas (see below), and has gone against the physician recommendation. The doula has provided excellent support prenatally to the couple, and then during labor to the woman, to her partner, and to the hospital staff. The doula has helped the couple to identify when they were ready to go to the hospital. They were able to labor in the comfort of their home because that was the decision that they had made prenatally. At the hospital, the labor nurse is relieved to have extra help because she has a great deal of charting to complete, not to mention caring for the patient in the room next door. The doctor possibly has popped in once or twice during labor and has had pleasant and respectful interactions with his patients and with the doula. The doula has been able to provide information to help the couple as they make decisions throughout labor. In the twenty-eighthth hour of labor (the average first labor is sixteen hours, this one turns out to be a bit longer), her partner, hungry and exhausted, asks for a break to grab a sandwich, and then falls into a deep sleep in a corner chair in the delivery room. The doula provides much needed relief, and the mother is able to relax and continue with the hard work of labor. Shortly, she is in transition and ready to push. Her partner is awake and ready to encourage mama as she delivers their baby. She may or may not have opted to have pain relief medication administered. A doula serves the couple and she helps to educate them about all aspects of labor and birth including the potential risks of medications. She is not hired to advance her own agenda, nor to make decisions for the parents, even though she may believe that an un-medicated labor is best for both mother and baby. The doctor arrives to scrub in and “catch” the baby. The doula helps ensure that the baby is latching on well to breastfeed after birth. She reminds the couple about their plan for post partum care for mother and for baby, just as she’s reminded them about their desires for labor throughout the birth. Post partum the doula visits the new family at the hospital, at home, or both, and makes sure that every member of the family is faring and transitioning well. She recommends services or books in case she notes the need, such as if she notes signs of post partum depression. She might do some light house-keeping for the new family. She provides continuity of care. The mother and her partner are satisfied and happy with their birth. They feel that they were empowered by their experience and well supported by their labor team throughout pregnancy, birth, and post partum.
In another scenario, the mother and her partner have decided not to hire the doula. In spite of hearing that in some special circumstances doulas work for reduced fees, the mother decides it’s unnecessary. She has the same thirty hour birth. Both she and her partner are exhausted and overwhelmed during labor and afterwards. We will not enter into all of the potential problems she may have encountered or interventions she received. Instead will mention the benefits of hiring a doula:
50% reduction in the cesarean rate
25% shorter labor
60% reduction in epidural requests
40% reduction in oxytocin use
30% reduction in analgesia use
40% reduction in forceps delivery (Klaus, MD, et. al)
In other words, without a doula, a woman has a significantly higher rate of any number of interventions. Although many women experience beautiful births without doulas, we feel that with advocacy and education, women can make informed decisions about the choice to hire a labor assistant, and about other issues concerning child birth. The goal is that families feel empowered by deciding how they will give birth and that they are supported by their practitioners.
In this current birth climate, where we have an insufficient number of midwives available to meet the needs of the women in the Cape Fear region and nation-wide, we encourage physicians to educate their patients about the benefits of having a doula at their birth. Where’s My Midwife? recommends that women who are considering hiring a doula have a conversation with their practitioner as early as possible. If they encounter resistance, they can provide statistics and information to their practitioners and have a respectful dialogue about their patient rights. A good book to read about doulas and to recommend to practitioners is The Doula Book by Dr. Marshall Klaus, MD (et. al.) A woman may also decide to ask for a referral to another practitioner if she continues to receive a negative response about hiring a doula (or about any other decisions concerning child birth.)
Have you had any negative reactions about hiring a doula from your medical practitioner? Please let us know about your experience and about the reasons that were provided. Please do not include names of practitioners or identifying information about them in your response. Thank you!
For more information about doulas, please visit www.capefearareadoulas.org.