Saturday, April 14, 2012

Doulas and Advocacy: Are they mutally exclusive?

I hear time and time again. I'm sitting in an interview with potential clients and they tell me that one of the reasons they want to hire a doula is to have someone advocate for them in the birthing room. I'm constantly explaining to clients that while I do consider myself an advocate of choices in birth, natural birth, and natural postpartum choices; I do not advocate for you during birth, but rather help you to advocate for yourself. I also explain that if they hire me as their doula, the process of how I help them to advocate for themselves starts prenatally.

I use to always wonder where these women and couples got the idea that doulas are advocates for them during birth. That is, until I started listening to my fellow doulas. Again, I'd hear over and over about stories of doulas who would get into heated conversations with doctors and nurses about hospital policy, clients wishes, evidence-based practices and more. I'd hear doulas brag about arguments they felt they won, shouting matching, standoffs, and more. The worst to me are the stories of doulas who unhooked IV's, stopped the pit machine, and spent time interpreting fetal monitor readouts. It was quite horrifying to me. Who was serving the mother at that time? How did this truly make her feel? Did these doulas really feel they served their clients best this way?

Now I understand there is a type of doula for everyone. Some women benefit from doulas with a more no nonsense attitude, the ones that don't sugar coat things or come off more "militant".  Other women prefer a lighter touch or a more "middle of the road" doula. I respect the differences and the need for them. However, I believe there should be a separation of doula and advocate. Politics, in particular your own personal politics, have no business at the birth of your client. Once a client is in labor, any personal agendas should be checked at the door. There is a more appropriate time and venue to try and change faulty birth practices.

I think the same thing goes for the myth that we empower women through these actions at her birth. A woman's power to advocate for herself and birth in the way she wants isn't ours to give. It's her birth and it has to be her job to find the power and be empowered. We can help, we can guide, we can even lead, but we can give that to anyone. Sadly though, through our actions, just like the hospital staff, we can take it away.

So people, what do you think? Do you think there should be  separation? Perhaps there is another side I am not seeing. Maybe you are a mother who benefited from a doula doing some of the things I mentioned above or a doula who felt there was no other way. Share your thoughts with me. I'm open to them.


  1. I agree with you that a doula shouldn't let her own personal views/agenda take over because that's just another way a woman's voice isn't heard. However, I would never want to separate doula from birth advocate. The sole reason I am getting a doula is because I'm having a hospital vbac and I'm worried that my wishes will be ignored and I'll be pushed into interventions. Of course I will stand up for myself but there may be times during labor where I will be particularly vulnerable and unable to make decisions. I will need someone to remind me of my birth plan and desires and someone who won't just sit in the background not saying anything. I need to trust she will 'have my back' for a lack of better way to describe it. I have a lot of anxieties having a hospital birth and I need a vocal advocate. I think there is room for a doula to act as such if that is what her client specifically asked her to do. If I didn't trust a doula would due this for me I wouldn't get one.

  2. Amen! I think there are ways to go about providing that "have your back" role without getting into it with hospital staff. I think some potential clients have the idea that doulas are supposed to speak for them, or speak to hospital staff on behalf of the client. According to my training, we're not really supposed to do that. We can speak very loudly to the client so everyone in the room can hear, "Did you want this? Did you consent to xyz? Do you need a minute alone with your birth partner to talk it over?" But I don't feel it's my job to say to medical staff, "She doesn't want xyz." In my opinion, to be the best advocate we can be, we need to have a good rapport with the hospital staff too. We need to let hospital staff know we are a team player and not out to be combative. And I also agree that most of the advocacy work we will do is help the mom during the prenatal time to encourage her to find her own voice. I'm not very experienced yet, but I have yet to see, with good prenatal preparation, a mama get into one of those moments where she's lost her voice. Even when unexpected things start happening, all I've had to do was tell the mom, "Remember such and so? Do you still want to do this?" And they are able to advocate for themselves.

    I would never want my doula to tell hospital staff, "She doesn't want xyz" because maybe at THAT point, I do. I could change my mind at any point. I would want her to double check with me first. And then that double checking will remind ME to advocate for myself.

    I try to make it clear that I will not become confrontational with hospital staff. This is the way I do things. I will say things to the mom, and then she speaks for herself. If they want someone to speak for them, there are other doulas who will.

  3. I guess it depends on how you define advocacy. I like the term influence, and I totally wanted my doula to help influence my birth so I had what I wanted. She was very good with working with the nurses -- and yet not working with them -- to create a good space for me to labor in. It can be complex.

    She was also very good at assessing/addressing my and my partner's initial and ongoing expectations so that wires weren't crossed. In fact, my partner was initially against a doula because he thought they interfere in birth.

    I am not a doula, but a childbirth educator. My deepest respect and awe for women who are doulas and directly help growing families!

  4. This is an awesome post. Thank you for addressing an ever-increasing problem (and it IS a problem) with doulas at births. It's this behavior that leads hospitals to ban doulas and causes nurses to groan when a woman comes in with one. Who wants to work with a laboring family AND a know-it-all that doesn't really know all that much after all?

    A doula's job is to support the mom during her labor and birth, not to be her voice or, what I've also seen happen, her care provider. A woman hires a doctor or midwife to be the care provider. If she believes the doula would be a better provider, why hire the doc/midwife at all? Doulas *do* have information in their birth kits and it's really great if she can share that with her client during pregnancy. I understand the doula-client relationship doesn't always allow for lots of teaching time, but there are ways to teach the woman during the labor.

    "It looks like they might want to start pitocin. Were you able to read up about this during the pregnancy? Do you want to talk about the pros and cons?"

    If there's a nurse that's irking your client:

    "I remember you told me you didn't want anyone to mention pain medications during labor. Are you still wanting that?"

    There are ways to appease the medical staff AND serve the client.

    Maybe there should be a separate class on this very topic. Another day dedicated to it during training. And maybe even some more blog posts. (I think I'll write one.)

    Thanks again for bringing this up. Great topic.

    1. At first when I saw this post I started to bristle, because I have heard too much of the opposite side of things lately - that a doula shouldn't offer information at a birth unless directly asked by the mother; shouldn't point out procedures, again, unless directly asked about them by the mother. When I had a doula part of the reason I wanted one was because I knew I'd be so far into labor land that it wouldn't always occur to me to ask (turns out that wasn't necessarily true - I was THAT type of laboring mom - "Huh? What did that nurse say? NO MONITOR!"). Navelgazing midwife, the approach you mention and the type of phrasing you use in your examples is EXACTLY what I use at births and I agree that this is an approach that serves the client while not creating a hostile atmosphere and almost always keeping things on a positive level with the staff.

      So thank you, Patrice, and Navelgazingmidwife, for this great discussion.

  5. The thing is, doula's DO NOT advocate for women. They need to take this word out of their vocabulary and stop the confusion. From

    verb (used with object) speak or write in favor of; support or urge by argument; recommend publicly: He advocated higher salaries for teachers.

    2.a person who speaks or writes in support or defense of a person, cause, etc. (usually followed by of ): an advocate of peace.
    3.a person who pleads for or in behalf of another; intercessor.
    4.a person who pleads the cause of another in a court of law.

    You'll notice that none of these definitions say, "teach people about a certain subject and then remind the person of what they wanted to do so they can speak up for themselves". I don't know what that is, but it is not an advocate. If I hire someone who calls herself an advocate, than I would expect her to speak up for me or speak on my behalf. I would not expect her to change the meaning of the word "advocate" and then try telling me that she is somehow "advocating" for me even though she is not advocating for me.

    Also, I don't know who these laboring women are who get amnesia as soon as they enter the birthing room and need so much reminding of the things they themselves wanted, but that certainly was not my experience. I did my own research, I knew exactly what I wanted, and I spoke up for myself and made my wishes known. That did not stop the hospital staff from manipulating, coercing, and forcing me to do as they wanted without giving me informed consent or the right to refuse. If my doula had turned to me as I was screaming, "no, I don't want this" and said, "do you remember that we talked about this and you didn't want an episiotomy" I most definitely would not have considered that "advocacy" by any definition. And it was not "advocacy" when I spoke up for myself either. You'll notice none of the definitions for "advocate" mention doing it for oneself. Advocating is something you do for someone else.

    So, if you use the word "advocate" to your clients to describe what you do then don't be surprised when they expect you to speak on their behalf because that is what the word means. Don't use the word if you are not going to do that. If a prospective client asks if you will advocate for her, say "no". Be honest. Let her know what to expect from you. Then she won't feel betrayed when you stand idly by while she is being mistreated by the medical staff. If you feel it more important for doulas to remain in good standing in hospitals than to speak up for individual clients, make this known to the client who is hiring you to speak up for her. Let her know that you are not her advocate, you will not speak on her behalf or speak up for her to hospital staff, and if push comes to shove there is really nothing you can do about it aside from witnessing it and then trying to spin it into a good memory.

    Don't get me wrong, I think doulas are a great addition to a birth team, I just think they have many limitations that they are not always upfront with their clients about. I think this leads to a lot of confusion and feelings of betrayal from their clients. This could all be avoided if doulas would just be honest about what they do, and don't do, and stop trying to rewrite the meaning of a word so they can use it. Simply stop using the word.

    1. I don't actually use the word "advocate" much, but I think it does have a place.

      For example, if my client wants to get in the labor tub, but the nurse is dragging her feet getting the tub room ready for her, I am going to advocate that she get in that tub ASAP. If my client has expressed that she wants the monitor off her to the staff, but the staff is again, stalling, I'm going to keep pushing that call button and asking if we can get a nurse in the room. If my client wants a birth ball or warm compresses or more pillows, I advocate for that.

      I am also a CBE and consider myself an advocate for natural childbirth outside of my role as a doula, but you'd better believe that if my client has expressed to staff that she needs an epidural and they aren't prompt about it, I will advocate for her to get it sooner.

      If my client wants/needs information about a proposed intervention, I will advocate for her to get that information.

      I will not, however, advocate that my client makes certain choices. I will not say to staff, "She doesn't want xyz." She has to say that. But once she does, I'm an advocate that her wishes are followed.

      All that being said, I pride myself in maintaining a peaceful environment and a good working relationship with hospital staff. It is not a service to a mother to speak for her. (Isn't that what we hate about what many care provders do?? Take away Mom's voice?) It is not a service to insist on our own views of how birth "should" be. Believe me, I have those views and I hold them strongly, but they are my views and I have no right to insist on my way when I'm with a client.

      I have had times when I have diffused an argument between a client and her care provider (SO unprofessional on the part of the care provider), and many times when I've spoken to the care provider to help a client get more info. And I've had these same care providers later refer patients who were looking for a doula to me.

      My point is that we CAN advocate, but there is a limit to advocacy, and we can advocate in a way that improves the client-care provider relationship rather than erodes it. (Usually. There are some care providers whom I feel there is no way to really work well with, so I kind of ignore them. At the end of the day, my client is whom my loyalty and responsibility lies with. I won't overstep the professional line, but I certainly won't stand by idly and watch them be mistreated! And it's never come to this in almost 9 years and I doubt it will, but I would rather never have a chance to be a doula again because all the hospitals have banned me than to stand by and watch serious harm come to a client or her baby.)

  6. I tell women I do not speak for them. I doubt I even use the word "advocate" except to say I will not be an advocate, but a support person who has a lot of knowledge about positions and wending my way through the medical maze, increasing the ability for clients to get what they want and have the birth they visualize through honey instead of with vinegar.

    The deal is, many (most) doulas DO advocate (as you define it here), but that advocacy has led hospitals to ban doulas. What good is a doula who can't even help a woman because nowhere wants to put up with their "advocacy?"

  7. "The deal is, many (most) doulas DO advocate (as you define it here), but that advocacy has led hospitals to ban doulas. What good is a doula who can't even help a woman because nowhere wants to put up with their "advocacy?""

    I have only experienced and read of the opposite situation, where a doula may call herself an "advocate" but doesn't truly adovcate as I have defined it above. I rarely encounter/read about a rogue doula who actually advocates. They usually act on their own without being associated with any certifying organization.

    But, the question you ask above I think is an ethical dilemma the way I see it. Does the doula shut her mouth and watch a woman be mistreated and assaulted before her eyes? Or does she speak up on the woman's behalf and get herself and all the doulas after her kicked out of the hospital? Does it help to have a doula if she can't speak up for you? Is it better to have someone standing by doing nothing (in addition to your partner) while you are being assaulted by the hospital staff? Is the trauma from the birth any less because a doula was there witnessing it? Will the woman feel any better about the birth if the doula can spin a pretty memory for her? The answer is no, the woman will deal with feelings of betrayal and anger for her doula and her partner for not intervening. When a woman is left broken and traumatized from a birth experience like this, understanding why her doula didn't advocate for her isn't going to make her feel better. She will deal with the effects of the trauma for years to come. She essentially 'took one for the team' so that other women will continue to have access to the doula that couldn't/wouldn't help her.

    But, since most women won't be mistreated, is it worth the sacrifice of the few to provide support to the many? That is what most doula certifying organizations believe at this time which is why they discourage their doulas from being actual advocates for their clients.

    I am not sure what the right answer is. I just know that I wouldn't personally be able to stand around and watch while someone was being illegally mistreated before my eyes. I would feel morally obligated to do something. This is why I can never be a doula.

  8. What would you do? How do you see someone intervening?

  9. Maybe: "Do you hear her saying no?" "She did not consent to that" "You are forcing my client to undergo a procedure she did not give informed consent to, are you aware this is illegal and against your own hospital's policy?"

    But I know this would get immediately get me kicked out of the hospital, so I would be forced to stand by and watch. Which I just don't have the stomach for.

    1. One thing doulas can do is help the actual birth partner advocate for her. I have pointed out procedures to dads and then they've said, "She did not consent to that!" That's a great way doulas can help. My own husband stopped a midwife from performing an unwanted vaginal exam this way, and a friend of mine stepped between a nurse and his wife. (I wasn't there - heard about it later.) Doulas can help birth partners be advocates.

      But here's another soapbox of mine. Most birth partners aren't going to have to confidence to advocate like that if they haven't gone through a good independent CBE course. I teach Informed Beginnings. (If you haven't heard of us, we're new, and we're a shared serveds co-operative of CBEs and we are a certifying organization. Check us out: Another good one for this is of course Bradley, and then there's Birth Boot Camp, which I'm guessing is similar.

      I do feel for those mothers though who don't have a birth partner who can/will advocate for them like this, or for whom their doula is their only support.

    2. That's "shared services co-operative," not "shared serveds." ;)

  10. Not to be confused with the first Anonymous poster... I'll be Anonymous Too.

    Anyway,good advocacy/support, or whatever you want to call it, that I have seen during birth, has been a doula that very directly guides/alerts her clients to advocate for themselves. She has said things like, "Your Dr. is getting things ready to cut your perinium. Do you want that or would you like to see about trying another position? If you don't want an episiotomy you need to say "NO" or "WAIT" now." She is respectful and matter-of-fact in her statements.

    When an intervention is suggested she tells her clients, "A pitocin induction (or whatever) has been suggested. What do you understand about the reason for that recommendation? What questions do you need to ask? Do you know your options? Now is the time to ask for a time alone to discuss things privately."

    I saw her help a mother ignore a physician's disrespectful chatter by simply talking a little more loudly to the woman's mother and directing the mother's attention to that conversation. She has informed mothers that they can ask to have things be different, which they would not otherwise have realized they could request or expect.

  11. Well, what about when an intervention could have saved the baby from a dire outcome but the doula stood idly by, offering false reassurances and generally behaving like a deer in headlights? We mothers know that medical decisions are in the hands of doctors, not doulas, but we nonetheless expect them to bring the benefit of their experiences to bear during moments of crisis. Don't we hire doulas so that they can be a source of support and wisdom? And doesn't a doula have a moral obligation to handle a crisis with integrity, bravery and strength, not cowardice (i.e., waiting to call the mother whose baby sat in the NICU for 30 days until 4 months later, only sending a text message)?

    I understand that women become doulas out of noble intentions and motivations, but this is a profession that involves potentially dealing with the most awful, profound tragedies that human beings can endure. It does not always come with a happy ending; sometimes the tears that are shed are not ones of joy. Please, if you are considering becoming a doula, ask yourself SERIOUSLY if you are ready to face human tragedy with the strength that it will require.

    1. @Unknown - Your reply brings up something that I wrestled with on a personal level. I was at two births with bad outcomes (both babies lived thankfully). The first one, I was traumatized. I don't even like saying that because nothing I felt can even compare to the what my client went through. I don't want to get into too many details about the birth (either of them), but the next day when I reflected, I was plagued by so many what if's all I wanted to do is lay with my bed under the covers. I didn't do the postpartum job my client deserved, or one that I think would have helped me as well. The next experience, I brought all that stuff with me, overcompensated, and I can say without a doubt over stepped my bounds during the birth. I was seeing the exact thing unfold again, mainly in regards to the epidural and staff management. Afterwards, I questioned, and rightly so, if should continue being a doula. I spoke to doula colleagues, my own partner and ultimately a therapist. I worked through it. But listening to you, and some of the other people commenting what I hear most is that some women need the doula who will intervene, and at times speak FOR you doing the process. I do hear what you are saying. My experiences though have shaped me into a different type of doula.

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  13. I am a doula. Our certifying organisation prohibits us from advocating and I believe that it is correct. Because of responsibility. The family themselves are responsible for their decisions, care providers chosen, things they do or do not consent to. I have been the mother in the headlights myself. It is so tempting to say- why did not my doula stop the episiotomy. But- doula is not a medical profession. What if she acts as if she is a doctor and stops the pit AND the baby is harmed? The women and her partner are the people who will live with the consequences (good or bad) for the rest of their lifes. They need to be the ones making the decisions. And if they have a care provider who is rude or bad? The parents made the decision to come to this hospital or call this midwife. It is their responsibility. So a doula can bring the mother back from feeling like a total victim, to taking some feeling of responsibility back to the woman. And doula can help the woman feel brave enough to ask - e.g. Did you understand what is planned? Do you have more questions?
    Doulas should also work on educating the society and care providers, but not during birth.
    Want to make different medical choices? Become a midwife. Want to help women as a doula? Help the women. Do not become her I-know-best mother, advocate. Women will not feel betraied if they will have a realistic idea of what doulas are supposed to do.
    The only times when I talk directly to medical staff are when I make some suggestions or clarify - e.g. Is it ok to get up from the bed with the monitor attached? Maybe the dad can hold the baby while the mom is being sutured (the baby is usually on the warmer)?
    Sometimes they say yes, sometimes they say no, because...
    I try to treat all care providers, nurses and assistants with respect. They do a difficult job with a lot of responsibility. If I start a fight during birth, who will benefit? The mother? She will suffer even more, because the care provider will be angry and aggressive not only to the doula, but mother as well.

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