When Midwives Don’t Recommend Doulas

Jun 17, 2015 by

MWBlogphotoSo your local midwife told a prospective client of yours that she didn’t need a doula.  You feel surprised, even betrayed, at her lack of support.  What’s going on?

First, the midwife is right.  No one is compelled to have a professional doula.  Some women have friends or relatives who can serve in that role.  Some midwives have an assistant or student who s/he prefers to doula her client.  Women and their families have needs in labor that a professional doula is trained to meet.  But there are other people who can serve in those support and communication roles.

Second, the midwife is wrong.  Midwives may feel that their role is to support the woman in labor as well as provide expert medical care.  Since they are there continuously as a doula would, they think they can fulfill both roles.  That can be true depending on the midwife, her assistants, and the events and length of the labor.  If a birth becomes medical, there are two patients to care for – the mother and her baby.  Unless there is a third person whose priority is the mother’s emotional wellbeing, those needs go unmet.  You cannot adequately address emotional wellbeing, especially in a medical crisis, if you are monitoring and conducting lifesaving measures on a mother, baby, or both.  You just can’t.

In addition, just because a mother may trust her midwife with her medical care, that doesn’t mean she is the ideal person to meet her emotional needs.  There are many times I have been hired as a doula at a home birth for just that reason. Sometimes the mother feels fine with the midwife but is concerned about her partner’s needs.  With a lengthy labor, having a third knowledgeable person with a professional attitude can be an asset to a midwife and his or her assistant.  All of us are less tired, we can nap more frequently, and think creatively about positions and comfort measures to try.  We are all on the same team, chosen by the mother and her partner(s) to be their support.

However, it’s also not that simple.  Doulas often have strong emotional reactions when this happens.  Doulas often imagine that since midwives and doulas are both professional birth workers, we would naturally support one another.  We recommend midwifery care.  We’re kin, right?  Yes and no.

There are some very emotionally supportive, hands on midwives. These ladies and men give a lot of emotional support and are instrumental in suggesting comfort measures.  Others sit and knit, quietly observing, and only get involved to do monitoring and the eventual birth and aftercare.  Most midwives are somewhere in between – and it may also depend on the clients they are working with.

Some midwives may feel a sense of competition with a doula; as if we are infringing on her territory or passing a judgment on her abilities.  They may even have begun as doulas and feel they can continue in both roles.  They may like the doula role and be unwilling to give that up.

Our histories are also different.  For over six hundred years, midwives have been maligned, persecuted, misunderstood, and demeaned. Lies were told about the abilities of Black Midwives in the American South in order for physicians to get their business.  The worst kinds of discrimination and injustice against women have occurred in midwifery history.  A legacy of this oppression is that they fight among themselves about what kind of midwifery philosophy and training is best.

Doulas, beginning as birth assistants or labor assistants, have been around in a structured way for about thirty-five years*.  I contend that our whole profession would not exist if there was universal access to supportive midwifery care that treated the whole woman.  We exist to fill a gap in the medical system and the American way of doing birth.  While doulas are begrudgingly accepted (sometimes enthusiastically), we do not face the same obstacles that midwives do.  Midwives compete directly with physicians for business, while doulas do not.

There are a lot more birth doulas than midwives in North America today, and with a lot less training and dedication than it takes to become a midwife.  Midwives may witness a revolving door of doulas in her community, and only want to work with certain ones.  After all, a labor can be a long commitment and in the intimacy of a home or birth center environment, the midwife may want to control who is there in a professional capacity.  Perhaps its not all doulas that are being discouraged, but its just sounds nicer to phrase it that way.

What if the midwife is in a hospital setting and still doesn’t recommend doulas? 

Does the midwife feel that the nursing staff is able to support and adequately provide for mothers?  Is there a history of negative experiences with a particular doula or a rotation of mostly novice doulas?  Maybe this midwife doesn’t recognize the emotional needs of mothers the same way most doulas do, or feels that they are adequately met by the way birth is done in their facility.

At other times, midwives see themselves as working towards the same goals as doulas.  Rather than feeling competitive, they realize there are multiple ways for an individual woman to get the support she’ll need for her birth.  They want women to have births they feel good about, which lead to strong mothering and optimal outcomes, but don’t necessarily have to be the provider.  These midwives usually recommend doulas.

So when you’re surprised by your local midwife’s remark, take a moment to consider these multiple perspectives.  Hopefully they will help to explain why she or he might make that statement.  What’s the best reply?  As always, the best doula reply is to turn it around and ask the mom!  “Why do you think the midwife would say that?” and follow her lead.

 

*Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean, by Nancy Wainer-Cohen and Lois J. Estner, published in 1983, was the first book to recommend a labor assistant. They cite a lecture from 1981 (p. 225-227).

 

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8 Comments

  1. Good article. I think there is something missing and it’s something I’ve encountered as a new(er) midwife that be it by luck or something I have had births with some (certainly not all) doulas that do not stay in their professional roles. Doula’s who have done vaginal exams or listened to heart tones prior to the midwife’s arrival and then misinformed the client as to what dilation was etc. One doula was urgently calling every 30 mins that “it was time, the baby was close” and as per my-the midwife’s-assessment, the mother was in very early labor and needed to rest but the doula continued to tell her the labor was progressing, causing the mother (and the midwife!) anxiety and exhaustion through an all night early labor. That same doula told the mom that she should have me rupture membranes at 6cm because that’s how all 7 of her babies came quickly. Eventually I couldn’t leave the labor room for fear of what the “doula” would tell her that I would have to correct. With me in the room she stuck to her role perfectly. Having to battle the doula who is misinforming, outside of her scope of care and making my client anxious and distrusting of me is not something I want to be spending energy on during a birth. I do encourage clients to hire doulas but I discuss these issues with them and make clear for them the different roles so they can better interview the doula. As a low-volume, very attentive homebirth midwife I definitely encourage more for the post-partum doulas especially for first time parents.
    On a separate and important note: I am a strong advocate that every hospital birth be attended by doulas either provided by the hospital (which has its drawbacks and benefits) or a third party…In order to mitigate the horrific birth culture that modern medicine and patriarchy have created for us all.
    Thank you

  2. Spot on! Thanks for putting this all together so well. It’s important for doulas and care providers to work well together so hopefully more doulas and midwives (and even OB’s, of course) will take these things to heart and improve relations with each other since we all want to serve our clients in the best way we can. Great blog.

  3. My midwife didn’t recommend a doula, and I definitely needed one. Her assistant functioned as my doula, but because I had never met her before she came into my birth space, I didn’t feel 100% comfortable, and had a hospital transfer from the lack of support and my exhaustion that I believe would have been prevented had I had a doula from the beginning forcing me to drink/eat and rest in between. I was too active and my husband was pretty useless. I’m a doula and a student midwife, and I absolutely encourage women to get doulas if they want one, or at least interview a couple to see if it feels right.

  4. Anita Roy

    An intelligent and sensitive article.

  5. Hi Amy – I enjoyed this piece and your perspective on what might be behind why a midwife might not see the value in a doula for their midwifery clients. Some time ago, I wrote a piece for the MANA blog that I would like to call your attention to now. It seems to fit. http://mana.org/blog/nine-tips-to-help-midwives-and-doulas-work-together

  6. Brittany

    There’s a lot of “the midwife might prefer this” or “the midwife thinks medical staff can fulfill the role”. Being blunt, and a bit tactless…but who cares what the midwife thinks? This isn’t her birth, nor is it her place to decide what support for her patient looks like.
    This blog is an insight to why a midwife might not recommend a doula…but there wasn’t a true good reason to back it up other then the midwives own personal bias about their role in the birth space and what others roles should be. What if the mother doesn’t want a nurse as a support person? What if she doesn’t want the midwife as a support person? What if she wants them too fulfill their clinical roles in her birth space, yet yearns for a deeper connection and advocacy from someone not clinical. Where the focus is solely on HER and not her baby?

    If I was a patient with a midwife who said, “no, I don’t recommend a doula because I have a assistant I prefer to doula you” I would transfer care. That midwife obviously doesn’t have my needs as a high priority, but hers.

  7. I agree…and disagree! While doulas have been accepted as support for about 35 years, I think we also seem to be replacing GRANDMA in many instances, a previously accepted role.mwe have knowledge about birth and Breastfeeding which has been lost or refocused since many grandmas now hold full time jobs…and may not have enjoyed natural births! Just a comment.

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