Tuesday, December 04, 2007

Doula : Midwife :: ____________ : ____________

You remember these from the SAT, right?

communication : telephone :: _____ : scissors

a) blades
b) metal
c) cutting
d) tool

I LOVED those kind of questions. And I just learned they're a lot easier to answer than to compose! But I digress.

In a previous post Kim asked what the merits/overlap would be in having both a doula and a midwife. I get this question from prospective clients all the time.

The answer (chime in doulas, midwives, moms with experience in this arena) is that because the midwife is responsible for your and your baby's health and well being, and the doula is responsible for your comfort and confidence, there's little overlap in the written job descriptions. The merits of hiring a doula -- continuous physical and emotional support during labor, education and empowerment in advance of labor -- are the same whether your health care provider is a midwife, family practice doctor, or OB/GYN.

In reality, things aren't exactly that cut and dry. If you are planning a homebirth, your midwife is likely to bring a team that includes her assistant and an apprentice. Because you're at home, your overall level of anxiety is probably going to be lower than at the hospital. And because you're planning a homebirth, you can handpick your birth support team to include the family and friends you think will best encourage and hold you through the process.

It is quite likely that in this environment, a doula will duplicate much of the support you'll already have present. Your need for reassurance will probably be lower and you'll have more people to provide it. I'm hoping this is the reason I have never gotten an inquiry from a prospective doula client planning a home birth. She doesn't feel she'll need anyone else.

While this is likely true, I would argue that doulas have a place at homebirths. Midwife friends have said to me that a common misconception is that your midwife will also be your doula. She will not. The midwife has a unique charge that includes making judgement calls about what's best for the mama's and baby's health. She might want to rub your back or hold you in the birth pool, but if heart tones are low, she'll have her ear to the doppler. At that time, the extra presence of a doula could be invaluable.

Similarly, some small number of homebirths end with an unplanned transport. When the midwife takes a patient to the hospital, she (usually -- see my midwife-blog-heroes for some hopeful counterexamples) loses any status as care provider. Depending how hostile the hospital is, the midwife may not even be allowed to go in with her patient. The doula might be one of the few people who could be present at home AND in the hospital to provide that continuity of care.

If you are talking about having a hospital birth with a nurse midwife, then the doula is every bit as important at that birth as at a physician-attended birth. CNMs in the hospital setting may be juggling multiple patients. Nurses definitely will be. Hospital policies will take priority over your and the midwife's preferences in most cases. For these reasons, a doula is a good idea. She can help you advocate for your wishes. She can help bring new CNMs and nurses up to speed at shift changes. She can be there with you every minute, even as the midwife pops back over to the clinic to see patients and the nurse checks in on her other beds.

A big advantage to having both a doula and a midwife is that they tend to be favorably disposed toward each other, at least from a professional point of view. Midwives usually view doulas as an ally. Doulas are more inclined to trust midwives' motives than O.B.s'.

My two cents is that the decision to hire a doula should be determined by where you plan to birth, rather than whom you plan to have catch your baby.

And now, any thoughts on completing the analogy above? It's hard because each of them has a relationship to the birthing mother but not to each other. Give me your best shot, but I think there is no relationship analogy between them.

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Anonymous Anonymous said...

Another reason you may not have received any inquiries from homebirthers is simply that they typically pay $2000 - $3000 out of pocket for their midwifery care, and they might have trouble paying your fee on top of that.

I definitely agree with you that a doula can be helpful at a homebirth.

3:14 PM  
Blogger Sandy D. said...


or is that too obvious?

I wish I'd had a doula with my first child - the CNM was dealing with two other women (both of whom delivered hours before me) and my dh was run ragged cleaning, fetching, helping. The second time around, we had a great midwife-in-training who essentially did doula duty (and happily, no one else taking my beloved midwife away from me).

4:16 PM  
Blogger Sandy D. said...

or doula:midwife::therapist:psychiatrist

I love these things, too. :-/

4:17 PM  
Blogger Kim said...


Because I'm in Canada, my perspective is a bit different. I don't have to pay for my midwifery care (paid for by the government) and midwifery (like nursing and medicine) is regulated by the government. Midwives are liscensed in Ontario to deliver babies wherever mom wants to have them! So, if a transfer is needed, my midwife has hospital privileges at both area hospitals with L&D units and would not have to abandon me to the system - YAY! They aren't employed by the hospital, so the hospital really can't tell them what to do, either.

As to the homebirth part, I haven't even much considered who I want with me for the labour. Definitely my husband, but I don't know many women who've had babies that I would want to be supporting me during that time. Hmmm ... I guess that's something I'll definitely have to think about! I'd want someone who's given birth w/o pain meds, that's for sure, since I will want the assurance that I can do it!

I asked the question because at my first midwife appointment, she said that when I go into labour and I page her, she'll assess me over the phone and if I feel I need her, she'll head to the house and check me out (ie. how far apart are the contractions, how do I seem to be handling it). If it's early and we are doing fine by ourselves, she'll give some pointers and suggestions for keeping labour moving along, and then she'll leave and check back on me later. Once I'm in 'active labour' she'll stay the whole time, and once I'm pushing, it's legislated that another midwife be there. All that to say, she suggested that if I wanted continuous labour support, a doula might be a wise idea, since she will not be there for the WHOLE labour (especially the beginning, since first timers can be in early labour for so long). She also said that a doula might provide a greater amount of postpartum support (ie. breastfeeding support) than what midwives are typically able to provide. What's your take on that?

Oh - and thank you so much for answering my question!!

4:24 PM  
Blogger connie said...

therapist:psychiatrist is a good one, except most people do not know that a therapist does not prescribe medicine and a psyc does.
i always use
doula:midwife::your husband:your doctor.
but usually only when i am being pissy!

4:53 PM  
Blogger Susan said...

Ooh...I love standardized tests.

I was thinking more along the lines of:
doula:midwife::florist:wedding planner

The wedding planner sort of oversees all aspects of the wedding. She is hired directly by the bride to do so. The bride can "over rule" her at any point--it's still the bride's (well, the couple's) wedding, but the wedding planner brings her skills and organization to the table and helps to organize the "big day" and inform the bride. She cannot get married *for* a woman, of course.
The florist is also hired directly by the bride. She doesn't work *for* the wedding planner and, although she will work closely with the wedding planner, she is ultimately answerable to the bride. Unlike the wedding planner, she doesn't need to worry with all aspects of the wedding, but can focus on the specific task of providing flowers for the ceremony and/or reception.

9:14 PM  
Blogger Susan said...

The problem with therapist:psychiatrist, as I see it, is that (if I'm correct) most people see one or the other--or at least see them one at a time. A midwife and a doula, though, work together. I mean, they may not meet until they both show up to the birth, but they will end up working together and interacting. A therapist and psychiatrist, even if they *are* seeing the same patient during the same period of his/her life, will most likely never work together.

More! More!

Can we do story problems next?

9:19 PM  
Blogger mamaloo said...

Like Kim, I;m in Ontario and my midwifery care is completely covered by my government health insurance (which all citizens get). My midwives have admitting priviledges at two area hospitals. My first midwife birth was in hospital and my second was at home.

One other point I'd like to make about doulas at homebirths (and even at one-on-one care midwife hospital births) is that some midwives do NO labour support at all. In fact my midwife left my home when I was going from 6-9 cms. When she was there, she was getting equipment set up and not bothering much with me.

My doula, who I let stay at her midwifery clinic reception day job until I was (I estimate) around 7cm, ended up being invaluable: I could take care of myself during early and early active labour, but by the time I was hitting transition, I was feeling out of control and unable to deal with my particularly intense/fast labour and could no longer self-direct. My doula got me onto the toilet and then a little later, when I was on my back and not wanting to move, reminded me that I really wanted to be in an upright position. She also helped get some food ready for after the birth - something I'm positive my medwife would never deign to do.

So, there is definitely a place for a doula at a home birth.

And, I like the florist : wedding planner analogy. I think that is the closest yet.

10:34 PM  
Blogger Kim said...

Mamaloo - thanks for sharing your experience! I think I've got this vision of my midwife being like Ina May Gaskin (lol) and being my one on one labour support person as well as the midwife ... I guess I've gotta change that thought process, eh? I'm becoming more and more convinced I'll be getting a doula =)

12:05 PM  
Anonymous Michelle said...

Another Ontarian here, and a doula to boot. I've been lucky to have quite a few homebirth clients in my mix and I'll agree the role feels a bit different than it does in hospital. However, what I've encountered is akin to what Mamaloo talks about; that there is a misconception that midwives do a ton of labour support and make the doula redundant. Not so! Our midwives encourage doula support for homebirths for the reasons Mamaloo described - we're there a lot earlier in labour, for one, plus all the other facets we play to that they cannot. I've had several clients get a doula for their second homebirth because they made the wrong assumption the first time and hindsight showed them where the roles would have been different and beneficial.

7:16 PM  
Anonymous katems said...

I'm a doula who has attended home births and a home birther who had doulas at her birth. I also worked at the direct-entry midwifery school (i.e. no nursing background required) where doula training originated. When the labor support course was introduced, there was a bit of tension among the midwives about it("are the doulas co-opting the warm, fuzzy heart aspect of home birth midwifery and taking it into the hospitals? will that discourage women from wanting home births?"). Over time the midwives came to understand the benefit of training doulas and promoting doulas in their practices. My midwives (the school's founders) were indebted to doulas, *loved* having competent doulas at births. It was their opinion that the less experienced midwives were less likely to promote doulas among their clients, but that the more seasoned midwives definitely valued doulas.

My own home birth experience was an all-hands-on-deck kind of birth. I had my midwife, her apprentice (a midwife in training), two doulas, and my husband with me for the 19 hours of active labor and pushing, and I needed every one of them. Okay, I probably could have done it with just one doula, but I wanted my friends from the birth community! Regardless, they all supported me *and* they all needed to grab some sleep at some point. But even when some of the birth team was snoozing, my continuity of care was never broken. I was simply attended to by another team member.

I heartily agree with the opinion that doulas are invaluable at hospital births attended by CNMs -- the nurse-midwives I've worked with are in group practices. Some women show up in labor and meet the midwife for the first time. Usually -- unless birth is obviously imminent -- CNMs will leave at the end of their shift. And they rarely labor sit, either by choice or necessity (tending to other laboring moms). There are, btw, many CNMs who are disheartened by the direction midwifery has taken in the hospitals. But that's another post.

1:50 PM  
Blogger One Hot Mama said...

As a midwife, I really feel doulas are helpful at a homebirth. As long as the boundaries are clear and the roles are defined -- I am doing the primary care, the doula is supportive care -- it makes it so much easier for me to concentrate on the medical/physical aspects. It is very hard to fill both roles. I love being the support for women. I love it. I love helping them through every contraction. BUT, when the birth goes on for hours and hours, leaking into days, I need to sleep to maintain a clear head. I am sure women dont want a fuzzy brained, sleep deprived midwife trying to resusitate their baby or sew up their bottom, or make a decision regarding transport. I can't sleep, however, when there is NO ONE else supporting the mom! I can't do it!

9:52 PM  
Blogger Sarah Stewart said...

I agree with one hot mama. I am a midwife in New Zealand and we dont have doulas per se. Years ago I would have been offended if a client wanted a doula as well as me. But now I always insist that a woman has a support person with them. Takes the pressure off me, especially if the woman has a long labour

12:57 PM  
Blogger doulicia said...

Great conversation, insight, comments, all. Thanks so much. Keep the discussion going! As a doula, it's great to hear from some midwives on the subject.

1:21 PM  
Blogger Kim said...

Thanks for all your valuable insight, everyone. I'm glad to hear that you midwives value doulas =) I think I might just start my doula search soon!

4:28 PM  
Blogger Oana said...

best friend::husband

3:08 PM  

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