There is such a deep chasm and fracture within the doula community regarding in-hospital and out-of-hospital birth. On the one hand there are those who say anything goes in supporting women and their choices. On the other, there are those who say no doula should support a woman in the hospital environment because it is a “bad and dangerous” place to birth,  or at the very least should get kicked out if she is doing her job “right”.

Who is right? This is where it gets tricky to be sure.

With upwards of 98% of the birthing women going to the hospital in the United States, are WE really within the general doula scope of practice by taking such a hard stance of ignoring those women in need? Who is benefiting here? It is well known, that I am all for a doula deciding her practice style, what scenarios she is best suited to support within, and knowing who she is best able to support.  But to abjectly say, no doula should ever support a woman in a hospital birth, is to me akin to very interventive practitioners who believe that birth is inherently dangerous and a trauma waiting to happen. Thus, viewing every women and baby through high-risk lenses and subjecting them to high-risk protocols where there is no medical need encourages more intervention and higher-risk scenarios to actually occur.

Who does this serve taking such a hard line? Perhaps those speaking it, thinking they are pressing for the greater good. Definitely not the mothers who need the support and assistance navigating a sometimes difficult and stressful system. The mothers and babies are caught then between a rock and a hard place. Then they are effectively forced to go without support and help. The truth is women having hospital births NEED DOULA SUPPORT MORE than women choosing an out-of-hospital option.

Bottom line: I make no claim that it is an easy task to doula within the hospital environment. It is not. It can be brutal. Imagine for a moment, really, close your eyes and think of what happens, what you witness as a doula when you are there — then think of all the women who have no doula present — what happens to them? What do those women experience? What do those babies experience? Now, open your eyes and breathe for a moment. It is not pretty is it?

Right there is what keeps me taking hospital birthing clients. It requires very open communication and immense work prior to labor during prenatals running through scenarios, detailing needs and desires, making certain informed consent and refusal is understood for a variety of procedures, medications, and cesarean. A mother needs to be well-versed in how to use her self-advocacy voice as does her husband, partner or other main support person.

Looking at the flip-side now.

So the other ideal, er rather idea, is that a doula should support anyone and anything because she is a doula poses other issues in my mind.  I do not see anywhere in the job description that this is what a doula ought do.  Any one doula cannot be the right doula for every mother or scenario. This way of thinking can fall into  a cookie-cutter way of practicing, thinking one can be all to everyone. Doulas are people too. Each has individual abilities, biases that need to be addressed, history and points of view.

I think it has been mistaken that a good doula is one that has no say in how she practices or who she is best to serve.  I believe there is a doula for every type of scenario and mother. It is a very individual pursuit and fit.

I know some amazing niche doulas out there who support only high-risk mothers, multiples, same-sex couples, in-hospital birthers, planned cesareans….. The list could go on.

Honestly, I will say there are some amazing doulas who can work under this very open practice style effortlessly and with excellence.  I applaud those doulas, though I think that is the minority and most are not able to keep it up without finding a comfort zone long haul.

Childbirth is such a deeply intimate and intense process with so many variables, being the right fit all the way around is necessary in my humble opinion.  I have seen doulas deeply wounded and traumatized by what happens in the birth room. Sometimes that is unavoidable, but through years of interaction with many doulas, the running thread is that the doula had misgivings even during the interview that this was probably not a good fit but chose not to refer the mother out to someone she knew was better suited for whatever the reason.

Are women and babies really being served best under this model of practice? This is for you to go ahead and answer for yourself.

Bottom Line: Women and babies need individual care whether from a doula, nurse, or care provider. Can a doula be all things to all mothers? Some, I am sure. Overall I believe not. For the health of a doula and the health of her ability to practice and support well, finding the “comfort zone” can make the difference for the mother, baby and doula. Why? Because doula work is such an intense giving of oneself (emotionally, physically, even spiritually). A continual self-assessment needs to be done just where her true and honest “comfort zone” is. By doing this, a doula is caring not only for herself by avoiding burnout, but also for her future clients and her ability to care for others with excellence and utmost professionalism.

There has been much ado surrounding the language of breastfeeding being normal and usual versus the best for baby and mother in great thanks to Diane Weissinger. It is so valuable to recognize that while we all desire to be the best, we often hit the normal everyday averages in life. We are comfortable reaching a goal that seems more attainable. Best or better can feel so far out of reach where average and usual seem quite in reach most of the time. None of us generally want to be below the average or usual. Thus the language of the risks of NOT breastfeeding is so vital.

I would like to see the same type of language revolving around pregnancy and birth as well.

In the overall picture here is the usual occurrence: Ovulation leads to heightened sexual desire, which leads to sexual activity, which leads to pregnancy, which leads to labor, which leads to birth, which leads to breastfeeding…..

So how do we look at language as an important part of our social fabric and belief systems surrounding this process?

Let us look at contrasting statements of what is often heard and how a positive point of view can be adapted.

Pregnancy is: a burden, an illness, an affliction, a mistake, something to be tolerated……

Pregnancy is: a gift, wonderful, amazing, part of the design, someone to grow…..

Labor is: scary, worth fearing, the unknown, unpredictable, painful, to be avoided, to be numbed from, to be medicated, to be induced, out of control, unfeminine…..

Labor is: what happens at the end of pregnancy, hard work but worth it, manageable by our own endorphins and oxytocin, an adventure, not bigger than the woman creating it, to be worked with, worth be present for, is what baby expects……..

Pushing and Birth are: terrifying, physically too difficult, only works for women who are not too small, short, skinny, big, fat, young or old, responsible for pelvic floor problems, out of control, horrible……..

Pushing and Birth are: what happens after dilation completes, to help baby prepare for breathing, bonding and feeding, sometimes pleasurable, sometimes fast, sometimes slow, able to occur in water, standing, laying down, squatting, on hands and knees, often most effective when a woman is given the opportunity to spontaneously work with her baby and body, not always responsible for pelvic floor issues, amazing, hard work, worthwhile, sets the finals hormonal shifts in motion for mother and baby……

Is it really BETTER? I say no. It is usual and normal.

• Spontaneous labor is not better – it is the expected usual occurrence at the end of pregnancy.
• Unmedicated labor and birth is not better – it is what the body mechanisms and baby expect to perform at normal levels.
• Unrestricted access to movement, support and safety in response to labor progression is not better – it is the usual expectation to facilitate a normal process.
• Spontaneous physiologic pushing is not better – it is what a woman will just do, in her way.
• Spontaneous birth is not better – it is what a mother and baby do.
• Keeping mother and baby together without separation is not better – it is what both the mother and baby are expecting to facilitate bonding, breastfeeding, and normal newborn health.

Denying the norms and adding in unnecessary interventions, medications and separation is creating a risky environment for mothers and babies. Thus increasing fear, worry,and even a desire to be fixed at all costs.

Perhaps even worse, an atmosphere has been created where the abnormal has become the expected norm and the normal has become the problem to be eradicated.

Bottom line, our language matters and will help shape for the positive or negative the future of birth.

Building a labor support team is a vital piece of conscious preparation during pregnancy in preparation for birth and life with the very newborn. Today as part of that support team many women are opting to hire a labor doula to come alongside them at the end of pregnancy through labor and delivery with some additional early postpartum follow-up.  For additional after birth support, a postpartum doula can be hired.

Step 1: Finding a Doula

• Inquire with friends, family, local support/informational groups (for example – ICAN, LLLI, Birth Network, Birth Circle), childbirth educators, care providers, prenatal massage therapists, prenatal exercise instructors, lactation experts and chiropractors for referrals.
• Use your favorite search engine and type in your city or area name with the keyword doula
• Search training and certifying organizations such as CAPPA, DONA, ICEA,  ALACE and CBI
• Search general doula sites such as All Doulas, Doulas.com, About.com or Doula.com

Step 2: First Contact

Once you have located local area doulas, the next step is a visit to make contact. You will likely find that most doulas are women though occasionally you will find a male doula in your area.  After visiting any applicable websites, phone or email only the doulas that most interest you and fit your particular needs.  Generally there is not much need to contact more than three perspective doulas.

During your phone conversation or in your email be sure to include:

• Full name
• Contact information
• Estimated Due Date
• General location where you live
• Care Provider
• Birth Location
• Top needs and desires for birth
• If referred, by whom
• Any financial considerations

Step 3:  Setting up the Interview

I encourage an initial interview via phone prior to meeting in person to get more of an idea for compatibility that email alone cannot offer.

• Unless the doula has an office, interviews are done in a public place such as a coffee house, restaurant, library, park, or shopping center. If you meet at a place where beverages or food will be ordered you can offer to pick up the tab for everyone if you desire, but it is not expected.
• Your partner, husband or other support who will be attending the birth needs to be at in-person interview.
• Expect the interview to be approximately an hour and to be free of charge.

Step 4: The Interview

The interview is to gain more detailed information from the doula, as well as, share more detailed information about yourself and what you want.  It is customary for the doula to bring a client packet with her that may include her professional background, client agreement, services, and support details and offerings.

Suggested Interview Questions:

• Why are you a doula?
• What is your philosophy of childbirth?
• Where did you get your training?
• Are you certified? Why or why not?
• How long have you been a doula?
• What is your scope of practice?
• What types of births have you participated in?
• What types of birth locations have you been to?
• How many births per month on average do you attend?
• How many clients would max you out in a month?
• Have you ever missed a birth? Please explain why.
• Do you specialize in working with a specific type of clientele or birth plan?
• What has been the most challenging birth you have attended? Why?
• How do you work with my husband/partner/other support?
• Have you worked with my provider before? If yes, please describe the experience.
• How many prenatal visits would there be?
• In general, what is covered in the prenatal visits?
• Will you help me make a birth plan?
• Please explain how your fee is structured.
• Do you have a back-up and do I meet her ahead of time?
• When do you go on-call?
• Do you labor at home with me?
• What do you do if I am induced or need to schedule a cesarean?
• When will you see me postpartum and what does it include?
• What are your expectations of me as a client?
• How long do I have to decide before you would contract with someone else around my EDD?

Of course that is a fairly long list of overview questions. Brainstorm some of your own. The interview is not meant to be a free prenatal visit, it is simply to find out if you and the doula are a fit personality wise and in how she practices.  Most doulas do not expect to be hired on the spot. You  need time to think over all the interviews before making a decision. If a doula is pressuring you to hire on the spot, that could be a red flag.

Step 5: Hiring the Doula

When you make your decision, please also contact those you are not choosing as well to let them know you have hired someone else so they will not be holding your EDD space open any longer.

Details to be clear about when initially hiring your doula:

• Sign and return the agreement/contract she gave you at the interview (if applicable).
• Payment  – First portion of fee is usually paid upon hiring a doula.
• Ask her usual business hours and contact preference for non-emergencies or labor related needs.
• Let her know your contact preferences and all phone numbers to reach you and your spouse/partner or other support.
• Set the date and time for the first prenatal appointment. Give her directions if your home is not easy to find.

Congratulations!

As practice through the ages and evidence shows, support during the birth process can be greatly beneficial to both mothers and babies. It is not about having an experience. It is about healthier emotional and physical outcomes for mothers and subsequently for babies as well.  Putting together a support team is not as simple as inviting a family member or friend along. There are many components to consider as this is the most intimate time to allow others to share in except for the conception of your baby.

Prior to putting together your Labor Support Team (LST):

You and your spouse/partner are generally the only persons who can speak on your and the baby’s behalf unless another individual has a medical power of attorney for the labor and postpartum time period. Learning how to be a self-advocate is an important piece of the support team puzzle.  Answering very specific questions prior to looking at who ultimately will be with you at your birth will be helpful to you in addressing specific needs, goals, philosophy, and expectations.

• What education and self study are you doing during pregnancy?
• Do you feel confident and equipped to birth your baby?
• Are you confident and at ease with your provider?
• Are you comfortable with his or her requirements and practice style?
• Are you comfortable with the policies, requirements, and protocols of your birth location?
• Do you have special circumstances or health concerns?
• When you close your eyes who do you see being the most supportive of you and your choices?
• Are you a single mother or is your spouse/partner deployed?
• What type of help does your spouse/partner or your main support person need?
• How involved does your spouse/partner or main support person need?
• What type of physical support do you need (massage, positioning help, any chronic pain or health issues to contend with?)?
• What type of emotional support do you require (affirmations, encouragement, quiet and positive, no questions asked, reminders…)?
• What type of educational/informational support do you expect to need?
• Are you comfortable discussing needs and desires with provider?
• Do you feel confident in addressing the staff at a hospital or birth center?
• Do you have a birth plan?
• Planning a natural birth?
• Planning an epidural in your birth?
• Traveling a distance to your birth location?
• Are there any specific cultural barriers or needs that ought be addressed?
• What other considerations or needs might you have?

Now that you have answered the questions, it is likely a much more clear picture why being specific about your LST is so important.  This is an opportunity to look at and personalize what is needed in labor.  It is not for anyone else to decide what it will look like, who is going to be there, and who is not going to be there.

Putting together your LST

The birth of a baby is only less intimate than the act of making the baby. Inviting anyone into the area surrounding this event can affect the process positively or negatively. Privacy, comfort, safety, and honoring the birth of a baby are a must so choosing the person(s) to take the journey with you needs to be well thought out. Some candidates for a LST are on the below list.

• Husband
• Partner
• Mother/Father (other family members)
• Friend
• Older Children
• Doula (skilled and trained labor support)
• Care Provider (OB, Midwife or Family Practice Doctor)

Many on the list are pretty obvious choice considerations. The best person(s) to have around you during labor and birth will aim to provide what you need physically, emotionally, and by way of information while supporting your decisions and desires without bringing in negativity, fear, bias against what you want, distrust for the process, anger, a sense of undermining, etc. Your support team can make or break the outcome of your labor and delivery simply by what he or she brings into your birth.  Your birth is not about any one elses satisfaction, background, needs, wants or the like. This is your birth, your baby’s birth.

The one person on the list you may or may not have heard of is the labor doula. The labor doula was born out of this need.  Essentially this is a woman of knowledge and skill in pregnancy, birth, and immediate postpartum (yes there are a few men in who are labor doulas as well) who comes alongside a pregnant woman (family) offering education, physical support and emotional support to both the mother and partner/husband/other support.  A doula does not take away from a husband or partner during the process.  Doulas are shown to decrease interventions, cesarean, epidural use, narcotics use, need for induction, and increase satisfaction, bonding, breastfeeding success, and more! For more information regarding labor doulas, click here  http://prepforbirth.com/2009/08/09/what-is-a-labor-doula-what-does-she-or-he-do/.

From the Birthing Front

Here is a sampling from women who have birthed, are pregnant or attend women in birth who answered the question “Why is having a supportive birth team important?

“…because a woman in labor is in the most vulnerable state of her life. When I was in labor I needed someone holding my hand telling me I could do it… telling me all those incredibly intense sensations were, indeed, normal. I was vulnerable, and my support team protected me and supported me as I gave birth.  “For me, feeling “safe” didn’t just mean feeling safe physically… it meant feeling emotionally safe to welcome the vulnerability that labor brings and thus to be able to let go” Lily B.

“Birth is one of the biggest events that define a woman’s life. When she is in labor her senses are heightened by the hormones going through her body. Her perception of those around her will make or break her birth experience. A trained experienced birth team knows how to keep the emotions of both professional and non professional people positive and empower the woman to birth not only her baby but a stronger more confident self into being.” Amber-joy T.

“A supportive birth team can mean the difference between a physically healthy birth and a birth that can take months to recover from. Regardless of the actual events at a woman’s birth (vaginal birth, cesarean, medicated, non-medicated, home, hosptial, birth center), a supportive birth team can also mean the difference between having a happy, rewarding, and empowering birth and a birth in which the birth is not owned by the mother emotionally. Mental health can be more important than physical health and more costly to treat down the road. Always take care of yourself emotionally.” Nora M.

“Birth is such a vulnerable and powerful experience. I remember that I had to tap into a side of myself that I had not yet known until birth. Every *vibe* from others around me affected my state of mind during the process. Without the complete support of my birth team, and husband, I would’ve when that point of surrender hit, given into the doubts and crumbled under the pressure; But becauseI did have a supportive team, I was empowered to press forward and experience the most amazing moment of my life uninhibited.” Julie W.

So now take a moment to think about who will offer you what you need and help you attain what you want in labor and delivery.  Having continuous support no matter the type of birth you want is important because you and your baby matter.  Your birth matters.