When asked about my role in the birth community, I identify myself as a birth activist and educator. A common follow up question is whether I'm going to become a doula or a midwife.
Like I'm a caterpillar...
So I'm finding myself saying, "no I'm just an educator," and I feel myself reinforcing a birth worker hierarchy that I'm totally opposed to... a food-chain that would look something like educators as grass, then doulas, OOH (out of hospital) midwives, nurses, hospital midwives, OBs... right? And we need to be nice to whoever is above us so they don't eat us.
My experience leads me to believe many OBs feel they can do everything a nurse, OOH midwife, doula, or educator can do; that a nurse believes they can do everything a OOH midwife, doula, or educator can do, that a midwife believes they can do everything a doula or educator can do, and that a doula believes they can do everything an educator can do. Maybe you perceive this all differently, but I'd like to talk about it.
We are not nesting dolls, these are all unique professions, we aren't just leveling up.
Local physicians have told my students that they will be their doula, and my own OB told me there is nothing a midwife does that he doesn't do (long story short, not true). I've been told by midwives that they are their clients childbirth educators and doula. I've sat in rooms full of doulas, as the only non-doula, and had all these beautiful women whom I totally admire tell me they don't refer clients to childbirth educators, because they are their clients' educators.
I know parents are participating too. I sit on several panels a year and I watch parents hold the opinion of the physician higher than the doula's, when at times, the MD may have little or no expertise in the subject being discussed and the doula may have a tremendous amount. Parents have shared they have hired a doula because she is in midwifery school, which I see the logic there, but there are doulas who are in midwifery school who are much less experienced than doulas who are... "just" doulas.
This is deeply irritating not because... I'm the grass, or the littlest doll... but because I know how this negatively impacts parents, and I want us all to do better by being honest about our expertise, our roles, and referring our clients to the appropriate people to fill the other necessary roles on their team.
In addition to this, many of the roles actually prevent practitioners from truly taking on the responsibilities of the other profession, or their responsibilities interfere with their ability to take on this outside role.
Let's look at doulas and educators.
I want all my students to hire a doula. I have volunteered at least a thousand hours (pulled out a calculator, or the calculator app, to confirm) to the promotion of doulas in my community for no reason other than the fact I know a quality doula helps people have a better birth. Some of my closest friends are doulas, and I will have a doula at any of my future births.
This doesn't mean I will support the idea that a doula is a childbirth educator just because education is one way in which they support (along with emotional and physical support). I'm fresh out of several courses designed with doulas in mind, and I hope doulas are considering how their role as a support person can interfere with their ability to also be a truly comprehensive educator. Also keep in mind, if your certifying organization offers both doula and cbe certs, this topic may not come up because they want to sell you more of their product. Education is such a critical part of a birthing person's prenatal preparation. How much can you really cover in two prenatals, along with everything else you should cover as their support person? What about when the information might put you at odds with their care provider, whose referrals you may want or you will soon be working alongside in the birthing room? How does that impact your client's education from you?
I recently completed a course in communication for doulas (that was wonderful, I'd recommend it to every doula) that was teaching doulas to communicate with, and educate their clients. However, they shared recommendations that completely undermined the doula's ability to educate in a comprehensive way, though did strengthen the bond between doula and client. This bond is essential, but is it smart to achieve it at the expense of the parent's education just so one professional can fill two roles?
I appreciate and frequently think about this passage from "Three Things Your Doula Can’t Tell You" by Cristen Pascucci of Birth Monopoly:
"My own doula and I have had more than one conversation about why she didn’t warn me about my own provider—someone who I now know has a reputation for not following through on promises to patients. 'But I asked you!' I’ve said to her. 'Why didn’t you tell me?'
She has explained patiently, each time, that she gave me the information I needed to make my own decision. What I wanted from her—to say, 'Oh, Cristen, you need to switch providers right now!'—is not something she would ever say to a client. Instead, she gave me specific questions to ask. She encouraged me to talk to my provider about my wishes and pay attention to the conversation, to trust my instincts, and to be honest with myself about whether or not I thought my provider was really going to follow through with what she’d promised.
Sure enough, I ignored the red flags. And sure enough, things came to a head with that provider. Finally, I switched care at 41 weeks, 6 days pregnant. (But that’s another story.)
Since then, I’ve talked to hundreds of consumers and doulas and have sat with them for hours in talks around the country, from Los Angeles to New York. Every single group of birth professionals said the same thing about their clients—sometimes in tears of frustration: 'They want us to protect them and we can’t!' and 'My job is to support them, but it KILLS me that I can’t tell them what they’re up against.'" (emphases mine)
I completely understand why a doula needs to choose the information they share carefully. Birth is an intimate event, it's important parents feel completely at ease with their doula. Same is true with OOH midwives. If a doula share's clear opposing or favoring evidence regarding an intervention, or a controversial newborn procedure like circumcision or vaccines, then the parents may take that as the doula being biased. The doula may fear the parents will feel unsupported in their decision that might be contrary to evidence, and that parents may hear "these studies show midwifery care has better outcomes than OB care," as "You made the wrong decision by choosing an OB." I've personally watched great doulas backpedal true but uncomfortable statements to comfort their clients. I don't completely disagree with this, I understand it, it's one reason I am not a doula. I present the evidence, I share stories, techniques, answer questions candidly (yes, even "what do you think of my provider") in a friendly and I hope engaging way, but will not also soften what may be a harsh truth or say positive things regarding decisions that I know work against the parent's desired outcome... I feel this role is important, and has a place, uncompromised by other roles. My experience is that parents want someone to plainly "tell them what they're up against" at some point in their prenatal care, and there needs to be a role carved our for that to happen.
There is nothing that I respect more in the birth community than a practitioner that frequently refers clients out to other complimentary practitioners. Have pride in your area of expertise, every one of these roles is absolutely indispensable.
If you are an OB and your patient wants a doula or a midwife, you will not fill that role, you will just have a less satisfied patient, maybe not the day of the birth, but someday when they have more information or experience. What you do is important, but different.
Midwives... you know I love you... half of my students who begin with OBs switch to midwives... but when you are being a midwife, you are not also being a doula. I've had a fair number of local families share they regretted not hiring a doula for their home birth, and often times they were told they did not need one. Doulas are not there to defend families against unnecessary procedures, home or hospital. The doula is there to provide continuous support in any setting while you chart, observe, rest... or so the partner can eat, use the bathroom, have a moment to collect themselves.
Doulas... I'm so grateful for you. I am lucky that in my community, doulas have embraced the need for comprehensive education for their clients. I'm concerned about burnout rates and the expectation that a doula should do it all, doula, cbe, placentas, photography, lactation... and how much of this is because of organizations trying to sell more certifications? I want to see doulas have long fulfilling careers doing what they love.
Educators... we provide the foundation. We present all the options and the evidence so that parents can make the important decisions that only they should be making. We help clients understand how a doula can support them, why a midwife might be an appropriate choice for them, or how to find an OB that is supportive of the care they want. Don't let anyone undervalue what you do.
Please network, connect with different practitioners in an authentic way! Midwives, sit in on your local CBE classes and Meet the Doula events and see how they can be of value to your clients. Doulas, keep the ass kissing to a minimum, you do noble work, expect respect for what you do. Doctors and nurses, come out and have a drink with us once in a while, come to birth network events, and hear our perspective and we will hear yours. We all make a great team if we'd all just let it happen.
In friendship and optimism,
Happy New Year
UPDATE: I am offering doula care periodically, only for families who have received the foundation of a quality, comprehensive childbirth class.