The NYT on Doulas

The Fasion & Style section(?!) of the New York Times has a piece on doulas this weekend. If you like headaches, check it out. Tempting as it is to deliver a point-by-point response to the article, I'm going to limit myself to a salient few (below), and instead focus my energies on the very valid question of what, exactly, a doula's scope might be, and offer a few thoughts on why doulas are at the receiving end of so much hostility.

Scope of practice: What the heck is a doula?
A doula provides emotional and physical support for a mother before, during, and after she gives birth. She provides knowledge, resources, comfort measures, advocacy, and suggestions to both the mother and her partner. She doesn't provide any clinical tasks or assessments, make decisions for the mother, speak for the mother, or control the outcome of the labor.

One of the biggest problems in defining the role of a doula is understanding what advocacy means in this role. I think it's vitally important that doulas discuss this with their clients well before the birth to ensure that everyone is on the same page about her role. My personal definition is that I don't speak for the mom, but I will make sure her voice is heard. No one can labor for the mom -- she has to do it herself. Likewise, I believe no one can empower the mother -- she already possesses the power to birth within herself, and all we can do is encourage her, boost her confidence, and do our best to help her feel comfortable (both physically and emotionally). One of my biggest beefs with both doulas and their clients is the very false expectation that a doula can somehow save a woman from her labor or her care provider. (And doulas, just like birth plans, are no substitute for communication with your care provider.)

An independent doula works for the laboring couple, specifically the mother, and no one else. A doula in a hospital-based program works for the hospital, meaning that she may be limited in what she can do or say in ways that an independent doula is not. For example, a hospital-based doula might be obligated by her contract to "report" a woman who eats during labor, while an independent doula would not. Ideally, I firmly believe that the doula should be a bridge between the hospital and the laboring mother, not a wall. However, if I were faced with a hostile nurse (and I never have been, seeing as how I'm awfully charming), I will always come down on the side of supporting the mother's wishes. I am most interested in the parents' satisfaction, though it's nice when everyone's happy! (So are all the other doulas whose thoughts I know on the subject.) And if a case were to arise where the parents' wishes conflicted with each other (say, the dad wants her to be on the fetal monitors continuously, but the mom wants to walk and try new positions), I will support the mother.

So, who determines the role of a doula? As the Times already pointed out, anyone can call herself a doula. ALACE, DONA, and CAPPA are three of the biggest certifying organizations, and they all pretty much define the doula's role in the same way. The differences in the organizations would take its own post to explore, but I'd say overall ALACE is the least discouraging of its doulas taking on additional roles, such as becoming a monitrice and checking dilation and fetal heart tones , as long as they understand that they need training beyond the scope of a 3-day doula workshop to do so.

Being a doula isn't rocket science, but I think that training and certifying with the above, or any other fine doula organization, is a good thing. For one thing, saying, "I'm a DONA doula," or "I'm an ALACE doula," means something. A potential client can learn what that organization stands for and make some assumptions from there. I also think that it lends credence to a doula's role as a professional to have some sort of formal training. Finally, I think clients deserve to have recourse if their doula is unsatisfactory, especially if she attempts to perform way beyond the normal boundaries of her role.

Shorter labors, fewer interventions (including cesarean), increased satisfaction... What's not to love?
Often, the doula is the scapegoat for anyone who was dissatisfied with the way a birth played out, whether it's a nurse who had to accommodate intermittent monitoring, or a mother whose birth didn't go as she had planned. Remember, having a doula doesn't guarantee a certain type of birth; also, just because a laboring mom who has a doula is declining cervical checks, that doesn't mean it's the doula's doing!

I'd be remiss in my bloggy duty if I didn't also address the fact that many doulas do step far from the cozy confines of their scope of practice. I have read things on message boards (told by the doulas themselves) that make me extremely nervous for their clients and for the fate of doulas overall. I can easily understand why an OB would feel angry towards a doula who, for example, is dosing the patient with herbs during labor or attempting to cut off conversation about options for managing a complication.

But for the most part, I think the hostility towards doulas stems from the fact that they tend to make things a little harder for doctors and nurses. Supporting women's choices, even when it goes against the standard protocol, is one of the most valuable things doulas do. So if a doula's presence gives a laboring mom the extra support to resist Pitocin, to spend time off the monitors, or the idea to try pushing upright, the good that does the mother is beyond measure. However, the hassle for other care providers may be quite quantifiable: extra hours, extra paperwork, extra explaining to higher-ups of why this labor was handled the way it was. I'd love to hear from some actual hospital L&D folks on this, though. Anyone?

And now, a few responses to the article. First of all, I commend the Times for pointing out that not everyone who bills themselves as a lactation consultant is an International Board Certified Lactation Consultant (IBCLC), which is a highly-trained, experienced medical professional. Folks, you don't have to have any letters after your name to give good breastfeeding advice, but if a new mother is having serious trouble, she needs to be aware that the "lactation specialist" nurse who comes to see her in the postpartum recovery room might not actually know that much about breastfeeding. Hospitals (and all care providers) must start being more transparent about their breastfeeding support.

That said...
  • Using a photo of a doula seemingly palpating a pregnant client's belly for the accompanying image... Why? Not that that is terrible or outside the scope of what is appropriate for a doula to do, but it almost seems like the editors are saying, "Look, here's a doula who thinks she's a midwife or something!"
  • Why throw in lactation consultants along with doulas? The fields are related, but their roles are very different. The article seems to have an agenda of "exposing" the bad behavior/advice of a small percentage of these practitioners. Which leads me to my final gripe:
  • I think, ultimately, few hospital-based birth professionals (and certainly not the author of this piece) understand the role of a doula. They may see the doula talking a woman out of an epidural and perceive that the doula is bullying her client. But often, she is simply fulfilling the role she was hired to perform. The doula Pamela Myers hired was perfectly within her scope to recommend avoiding IV fluids (as long as the mother hydrated in another way like, say, drinking water!), and firmly recommending a shower or bath is a time-tested method of pain relief.

    Walking out on a client who accepts an epidural is, obviously, very poor form. However, the article admits, "In an era of nurse shortages and high Caesarean rates, doulas and lactation consultants can be godsends for many women. Indeed, multiple studies show that a doula’s presence during childbirth leads to shorter labor, less medical intervention and a happier experience." And then adds, "[F]ew women readily admit to doula discord." What, then, is the point of this article?


Amie said...

I just have to add that not 3 weeks ago, I fairly heavy handedly convinced a laboring mother to get into the tub for pain relief. At her post partum visit, she reported the tub as one of the BEST parts of her labor. So, I don't think the doula acted inappropriately on that account. Not taking IV fluids also doesn't cause contraction spikes. This article makes it sound like the doula was somehow responsible for her painful labor! It sounds like there was a severe communication deficit between doula and client, since Pamela Myers was seething silently in the shower instead of getting out and saying "this isn't working for me...what else you got?". I also don't condone leaving a client once she has accepted an epidural, but I do support doulas only wanting to work with women who have a desire for unmedicated birth. This work is extremely time-consuming and exhausting for very little pay, and doulas have the right to say which kinds of births are worth their sacrifice.

Aaron said...

You'll notice that all the examples she cites are in the DC area. This is the birth wilderness we live in. The attitudes she inserts into the article, that natural childbirth and exclusive breastfeeding are extremist ideas, are fairly common here. And everyone on our local bulletin board has a few anecdotes which 'prove' the same points that this author is advocating.

Also, there are so few doulas out here that they are always booked up for months. It doesn't surprise me or bother me that they are selective about their clients. I think a doula would be useful at any birth, but I think a doula's tools are most useful when a woman's entire midsection isn't numb.

I think the doula and LC are lumped together in the article because they are part of the same 'camp.' In DC everything is a zero sum game with two, diametrically opposed sides.