“You Don’t Really Need a Doula”

“You Don’t Really Need a Doula”

Most of the time, when I get a call from a potential client looking for services, the first words out of her mouth are, “My practice gave me your number.” Her midwife or doctor, discussing her birth wishes during a routine appointment, said, “Here, call our doula. She’ll help you.”

Every now and then, though, I’ll hear something more like, “I hope you’ll work with my midwife. She said I don’t really need a doula – that if I want one and can afford it, that’s alright, but she’ll do everything a doula would do. I still really want one, though. Do you think that’s ok?”

This boggles my mind.

Almost always, a doula is a welcome addition to a birthing woman’s care team. In a hospital setting, the doula, the midwife, the doctor, and the nurses all have different roles. The doctor or midwife’s primary job is to attend to the medical safety and wellbeing of the mother and baby. The nurse’s role is to track a mother’s vitals and labor progress, and report to the doctor or midwife any information that may mean that this birth needs help. She may be offering this care to three people at a time, and might see a dozen or more birthing people in the twelve hour shift that she’s there. The partner’s primary role is to love the mother in whatever way comes most naturally. It’s the doula’s role to provide one-on-one non-clinical support throughout labor. This might mean offering simple comfort measures, suggesting position changes, words of encouragement, information for decision making, or just keeping the space calm and quiet – whatever the birthing person needs.

Usually, the doctor or midwife is most actively involved in the “home stretch” of labor, when the baby is about to be born. At the time they are most needed, a midwife is paying attention to many things at once. Their internal dialogue sounds something like, “How’s the baby’s heartrate? Does it seem like the baby is ok? Yup, looks good. How much blood loss is this? Some, not too bad. What position is this little one in? A little crooked, but head’s moving out just fine. Good. How’s this perineum? Give it good support so she doesn’t tear… Where’s that olive oil? How’s mama’s heartrate? How’s her blood pressure? Ok, all is well there. Oh, this fluid isn’t looking so clear… how’s baby’s heartrate now? Went down a little, coming back up fine. Good.” There are a hundred thoughts at once moving through the practitioner’s head.

At the same time, out loud she’s saying, “Ok, Jane, you’re doing fine, just little pushes now. That’s good. You’re doing great.” When something doesn’t look great, which can happen suddenly, she’ll know exactly what to do for the safety of mother and baby. The biggest work of the doctor or midwife happens in short, intense, highly-focused bursts. Like Olympic athletes, they stay calm and make it look easy only because they’re very good at what they do. If they’re a hospital practitioner or in a busy birthing center, then after this birth, they may be called upon to do the same thing six more times while they’re on call in the next twenty-something hours. In a homebirth setting, she’ll need to rest up and practice good self-care in case this is one of the weeks that all four of her current clients go into labor right in a row.

The doula’s work happens in longer stretches of energy and effort. We aren’t responsible for checking blood pressure or doing cervical exams. Though this information is beneficial for those responsible for a mother’s medical wellbeing, those tasks fall outside of our doula role. Our job is to tend to labor support. Prenatally, we spend our hours getting to know you and your wishes for your birth. We talk at length about your hopes and fears. We talk about what calms you when you’re feeling scared, or perks you up when you’re tired. We’re available every day to answer your questions. We learn what is most important to you for this birth, and support you in learning how to help that happen. We spend long hours in helping you get through early labor, when it’s too soon to go to your birthplace or call in your homebirth attendant. We help you figure out when it’s time to call your doctor or midwife, and when it’s time to go to the hospital. We make sure your partner is rested and nourished. We help you communicate with the people who provide medical care for you and your baby. We provide physical and emotional comfort when labor gets intense. By the time your baby is emerging and your trusted caregiver is most needed, the bulk of our work is done. Supporting your labor up to this point might wear me out, and that’s ok. That’s what I’m there for.

For a primary birth attendant, whether doctor or midwife, to practice both as doula and perform in their own role would be irresponsible medicine. Prenatally, it would be foolhardy for your doctor to spend the fifteen minutes he has with you to talk about what calms you on a stressful day instead of talking to you about your latest bloodwork and your baby’s growth. In labor, there is no way one person alone could maintain hip squeezes, breathing through every contraction, and giving pep talks for twelve hours at a stretch, and still remain sharp-witted when their knowledge is most needed to ensure that all is well. From a simple logistical perspective, it’s impossible to support someone’s perineum and also whisper in her ear and wipe her brow with a cool cloth at the same time!

A good doula knows that when a medical judgement call is in order, that’s outside of a doula’s scope of practice. In that moment, it’s the doula’s role to stay out of the way, and to help the birthing couple to understand what is happening and why. Likewise, a supportive practitioner knows that when doula support is desired, having a qualified doula on the team is only going to serve to make the person in his or her care happier with her birth experience.

So, if you’re one of the lucky ones who has found a practitioner who says, “Here, call our doula,” cherish them. Know that your care is in excellent hands. You’ve found a practitioner who cares about your wishes and wants you to be happy with your birth experience. And if yours is the practice that says, “Ugh, I don’t like doulas,” or “Don’t call a doula, because I’ll do everything a doula would do,” I encourage you to question why wanting this support for yourself would ever be considered a bad thing.

You deserve a birth you feel good about. You, your doctor, your doula, your midwife and your partner are all playing different positions on the same team. We’re all in it together. Everybody wins.

31 Responses »

  1. So true… as a student midwife who used to be a doula I totally agree with this. I thought I could do both but it is impossible and although I will try and support a woman as best I can, the constraints of the workplace plus the differing roles don’t allow me to give a woman everything she may require for her whole birthing experience. The best care would be from a good midwife plus a doula!

  2. I’m a homebirth midwife that was a doula prior to becoming a midwife. I still occasionally take on doula clienta that are birthing in the hospital. While I would never tell a woman not to get a doula, in all honestly I really dont love them at homebirths for multiple reasons. There are 3 of us at homebirths, 2 midwife’s and a student. At least 2 of us at all births have formal doula training. And I really love providing labor support myself. That’s one of the reasons I choose to become a direct entry midwife instead of a hospital based CNM…so I could provide 1 on 1 care. I’ve also worked with a few doulas at homebirths where they took the same approach they do when attending a hospital birth….that one of protecting the mother and fighting off the system. I hardly ever intervene at birth and had to spend my time convincing the doula why this was an appropriate time and place. I also had a doula try to tell the mom that she didnt need a c/s, despite my recommendation to transfer to the hospital. So overall, while I think doulas are an important part of hospital birth, I haven’t seen them to be beneficial to birthing at home, and actually, I think they’ve caused more harm then good. I’m able to say this with the unique perspective of being both a doula and midwife.

  3. Thank you for this article! As for the comments made by Lisa, good points about the Doulas treating homebirths like hospital births and being on the defensive. However, painting with a broad brush there, not all Doulas do that and some know how to behave in each setting. Just like not all midwives are amazing and great and show up as soon as Mom thinks she needs someone. Some midwives don’t have two other people working with them, some prefer a Doula to be there early on when they don’t want to be there yet. Some midwives are not much different than OB’s. I have worked as a Doula for nearly 30 years, in all settings, with no criticisms on my behavior ever. Rather than saying “you don’t need a Doula” perhaps saying “you need a Doula familiar or experienced with midwives and home birth practices” would be helpful?

    • Yes Kelly, I agree, not all midwives like to provide labor support, or are skilled at it, or have enough help at a birth to do so. It is important when hiring a homebirth midwife to find all that out. And as I said, I would never tell a woman not to hire a Doula. It is her birth and if she wants a doulaDoula there, she should have one. I’m only stating my own personal feelings, but I don’t share those with clients

  4. I had a doula with my first pregnancy. I don’t understand the hype. She was rather obsolete, as my husband was my main support, as he should have been. I ended up being pretty irritated at all her ‘just one more push’ patronizing comments. Get out of my face and quit telling me there’s only 1 more, when i’m only halfway through. We all know that’s a lie, sweetheart.

    I have had 4 babies since then and didn’t need or want a doula during any of their births.

  5. Thanks Jodi! I am definitely going to keep this article around as a reference for would be clients and perspective provider partners…Everything you said was so on time. A collective sentiment from our passionate hearted vocation indeed…

  6. I think you should really look at the reasons why a midwife would say that. They probably include:

    * Trying to save the mother money
    * They actually have a low enough client ratio to be able to insure full-on one-on-one care
    * They’ll have an assistant or student (or both) with them
    * They’ve run into personality conflicts with doulas

    Most of them would never say that to be mean to doulas, or to edge doulas out, but you have to admit that as stated above, that sometimes a doula can be a hindrance rather than a help to the mother.

    • I’m sure that no midwife would say “you don’t need a doula” without having her own reasons for saying so. I’m equally sure she thinks those reasons to be very good ones. My reality and my point of view simply differs from that. Even when available to provide one-on-one care, it remains true that the roles and responsibilities of doula and midwife are substantially different, and cannot be offered by one person simultaneously. The midwives I work with are always appreciative of our performing these different roles together in a harmonious and cooperative way. She’s tending to mother and baby and a safe emergence, while I’m providing physical and emotional comfort measures during labor and birth. If a doula is providing her services in a way that interferes with the midwife’s role, such as saying “don’t listen to her, that’s not necessary,” she’s operating outside of her scope of practice. That’s wildly inappropriate, and should be reported to the doula’s certifying agency. While that does happen sometimes, a good doula will know how to offer care in a way that works in harmony with the primary caregiver.

  7. I disagree with this: ” Even when available to provide one-on-one care, it remains true that the roles and responsibilities of doula and midwife are substantially different, and cannot be offered by one person simultaneously”

    While the responsibilities are different, as long as a complication is not occurring, it is certainly possible to provide both labor support and monitoring of both mom and baby by one person simultaneously. You later allude that the safe emergence of mom and baby is the midwife’s only role, and for some midwives, that may be true, but for many others, it’s not. If a complication occurs, yes, the responsibility of the midwife must be to attend to the health of mom and babe, but fortunately we have at least 2 and often 3 at a birth, so there is someone there for moms emotional needs if an urgent matter develops that takes the midwife’s attention away.

    • Lisa, I understand that when you are serving, you bring two other people along with you, at least one of whom has formal doula training, right? In that instance, at least one other person on your team, or perhaps even all three of you at different times, is in the role of providing labor support. In my mind, that falls far closer to saying, “here, use my doula, I’ll bring her with me” than “you don’t need additional labor support because I can do everything all by myself.” You’re seeing to it that a labor support person is already on your team. I think it’s great that you have support people on your team that you feel really confident about. I hope that the midwives I work with feel equally confident in me when they say “please call our doula.” They know me, we’ve worked together for years, and they’d rather have me than a person they don’t know, likely for the same “stepping on toes” reasons you mentioned before.

  8. Jodi, you don’t get your own reality.

    Reality _actually_ is:

    Sometimes mothers want a doula. Sometimes they don’t.
    Sometimes mothers can afford a doula. Sometimes they can’t.
    Some midwives provide just as good and even better emotional support than some doulas would–and midwives have way more training for that than doulas do, in addition to their clinical skills.

    You’re not giving midwives due credit in their ability to provide emotional support. You’re going to stack their years of education and training against your weekend certificate? It’s not going to fly. I’m sure you have had midwives that have appreciated your support of mothers, but they would not appreciate you saying that they don’t have what it takes to support a mother through a birth if you weren’t there.

    • True, sometimes women don’t want a doula. Sometimes, women can’t afford doula services (though there are ways of obtaining affordable doula support in that case, if it’s desired.) It’s also true that sometimes, women don’t want a midwife, or even a vaginal birth. I respect the rights of each woman to make the choices that are best for herself.

      The scenario my post is addressing, however, is that of a woman wanting a doula, and being told that she doesn’t need one because a single practitioner, on her own, will do everything that a doula and midwife or OB would be able to do together. It’s not possible for one person alone to do everything that two qualified people working harmoniously in their own different roles can do together, especially when that is what the client desires in the first place. It’s possible that good doula support and good midwifery or OB care can happen hand-in-hand to enhance this woman’s birth experience.

      To be sure, I know many midwives, each of whom provides stellar emotional support in her role, and they have my deep respect for the work they do. Their warmth, compassion, knowledge and incredible clinical skills are part of what makes me love working with them. I know also that they work their butts off, and I only hope that my support makes their work just a little easier that day. They can do their job spectacularly with or without me there, certainly, both because they’re already good at what they do and because their job is not the same as mine. It would be harder, however, to do everything that could be offered by both her job and mine, working together at the same time, entirely by herself. I wouldn’t dream of thinking I could take their place. I know I couldn’t. And, when a client wishes for a doula, I hope the docs and midwives I work with wouldn’t be the ones to say “Ugh, I don’t like working with doulas.” Likewise, I can do my job alongside many different practitioners, with many different styles of care, and I acknowledge that having a really good primary provider makes a world of difference for the birthing woman, even when she also has a good doula. I wouldn’t say “you don’t need a good provider, you have me.” We’re different parts of the same team. If birthing with a midwife and a doula is what a birthing woman desires, I see no reason why we can’t work together, both doing our personal best with the skill set we have, to provide the experience someone wishes for.

  9. I do believe you’re interpreting the scenario to make it seem like that the midwife is discouraging the mother from having a doula–she’s not. She saying she can provide emotional support that a doula provides, which, yes, if she has a low enough case-load, she _can_ do.

    And the extra person doesn’t need to be a midwife’s assistant _or_ a doula. It can be the partner, a good friend, a relative, etc., etc.

    No, no one _needs_ a doula. It can be nice to have one, it can improve outcomes. But let me repeat: No one needs a doula.

    A provider _is_ needed (I’m not trying to take anything away from those who go UA when I say that–usually women do that when there’s no provider available to facilitate the type of birth desired.) And I think that’s your problem: you have to let go of a doula not be needed, but wanted, whereas the midwife is needed and also wanted.

    • With all due respect, Gwen, in the conversation that I personally had, yes, the goal was to discourage the mother from having a doula. I agree that a good friend, a relative, and a partner can be an asset to the team as support people, yes. They’re not doulas. Different role.

      And you’re right, nobody has to have a doula. Nobody has to have a midwife, for that matter, or an OB, or even a vaginal birth. Everyone has the right to her own choices.

      When a doula is desired, a doula and primary provider can work together to support a woman in having a positive experience.

  10. I agree and disagree with much that has been said here. But I too as a doula have had midwives tell women they don’t need a doula. Not often but it has happened. I have also had doctors do the same thing – on a more regular basis. As for Lisa…yes, there are doulas who overstep. This is why it is important for doulas to have good, solid training with an organization who insist they follow a scope of practice and code of conduct. We have many women calling themselves doulas who have no formal training and while not all of them overstep…many do. As do many who are trained and even certified however, then as a midwife you have recourse with their certifying organization. I am a doula trainer with CAPPA and we also teach about building bridges and knowing your scope of practice.

  11. Jodi, thank you for speaking your truth! There are many doulas who also have had this experience, including myself. I think it is the height of presumption to tell any woman that she doesn’t need a doula. Who are you to say what the woman needs? Only she can make that determination. You have the right to the opinion that in a homebirth setting (or wherever), with a midwife who brings enough support, that a doula isn’t absolutely necessary. But you should keep that to yourself. If a woman wants a doula at her birth, she should have one. Hands down. Family and friends at a birth are WONDERFUL, and if the mother wants them there, she should have them. Friends and family (and even the partner) are NOT doulas. Its the woman’s birth, its her choice who she needs at her birth.

  12. Why would a woman, even if she wants a doula, _need_ a doula? You keep insisting this is something she needs. So, in addition to above, you also doubt a mother’s ability to get through her birth the way she wants without a doula.

    It’s really insulting. There are many paths to a woman having the birth she wants. A doula is only one option. If a woman wants a doula at her birth, but can’t afford it (and no, there’s no always a low-cost doula available), does that mean she can’t have the kind of birth she wants? NO! There are other paths to get there.

    • It’s true that no woman has to have a Doula. It’s a choice, just like she has a choice of birthplace, her choice of care provider, her choice of coping techniques, and her choice of support people. There’s no one right way, in my view, to have a baby. A woman’s right to make her own choices is worthy of respect.

      What I have chosen to address here is the all-too-common scenario, of which I have been part both personally and professionally, in which a woman desires a Doula, and is discouraged from having one by her practitioner, particularly one who says “I can do everything your doula would do all by myself.” Who knows, maybe she can. More realistically, two people working together will be able to offer more. Or, maybe they won’t. In any case, a woman has the right to have exactly the team she wishes for, including that of a Doula and a midwife.
      Maybe she can afford it, maybe she can’t. Well her baby get born anyway? Of course. Will she be content with her experience either way? Perhaps. Or perhaps not. But that’s the case with any birth, regardless of care team.
      In the cases in which a Doula is desired, Doula and primary provider working together in harmony can be a big part of creating a positive experience. That’s my story and I’m sticking to it.

  13. gwen… i struggle reading your posts… sorry to be rude, but it feels like you are just trying to create an argument. No one is saying a woman NEEDS a doula, just that if she wants one, she should have one and that a doula and midwife have different roles. Of course not every midwife can supply the required care – it depends on the birth setting and the midwife. The midwife at the hospital who says she can do everything a doula can may not be on shift when the woman labours (leaving her to the care of perhaps someone less caring), she may have her shift end halfway through the labour – she cant attend the womans home if the woman is trying to stay away from the hospital untill in heavy active labour… the list goes on. Each situation is different.
    If you feel that as a midwife you can do everything a doula can then i would assume you have doula training and have attended a number of births as a doula??? If that is the case I would be suprised you still hold that view. Yes I am only a student midwife (previous doula)… but I can say with confidence that the places I have been on prac have certainly not supported doulas in their role and they have NOT in anyway aimed to provide the woman with the care a doula would. Some midwives could provide doula care and if they are lucky and the births dont have any medical emergency then thats great… but I am sure that a midwife who aims to do this at the birth of every woman she attends in labour would burn out very quickly…. VERY quickly….

    • Jane:

      You are sure that she would burn out…despite the fact there have been countless midwives throughout the ages who have been the sole provider–just the woman and the midwife–that have provided complete emotional and physical care for each woman, themselves, all without burning out.

      History does not support your theory.

      I am a certified doula, and I have attended many births, and I have seen much from the hospital as well and homebirth and birth center, read a lot and spoken a lot and written a lot. So so much for _that_ theory as well.


      Your statement “In the cases in which a Doula is desired, Doula and primary provider working together in harmony can be a big part of creating a positive experience” is the only thing you’ve said that actually has truth to it. Bravo.

  14. Oh, by the way: doula is _not_ capitalized. Again, you’re trying to put doulas above something else…stop doing that.

    • Gwen, I believe that’s the only statement I’ve made. The scenario I addressed is that if a woman wanting a Doula (which my phone capitalizes by default, dyslexic on a software keyboard) and being discouraged from doing so by her midwife, who happens to work in a busy hospital practice.) I’m glad to know you agree.

  15. so gwen… as a midwife in the hospital system… how do you provide care to a woman in the same way as a doula would if you cant attend her at home? In the home system how do you provide care to her if you have been working over the allowed number of hours (In australia I think its 12 hours) ?

    • Jane, I’m not talking about midwives in the hospital system. In the U.S., you don’t have that much available support in hospital, and if you want one-on-one care, it has to come from someone other than your provider and labor nurse. But that doesn’t necessarily mean a doula.

      And homebirth midwives know how to take care of themselves. They take naps earlier in labor, eat, etc., so they’re able to provide the care needed at birth. There is no “allowed number of hours” here.

  16. Jodi, it’s obviously _not_ the only statement you’ve made. I’ve argued with you over multiple days and comments. If that had been the only statement you’ve made, I wouldn’t have.

    • I agree you do seem interested in argung, though i don’t know why. My point remains that when a woman desires a doula, it is unnecessary and even unsupportive to be discouaged my a provider. We have different roles and can work together.

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