Doulas – are they endangering the practice of midwives and the lives of mothers and babies?

Antenatal Support HertsToday I read an interesting article titled “birthing doulas accused of being a cannibalistic cult” featured in a Spanish newspaper in which the Spanish General Nursing Council is accusing Doulas of endangering the lives of mothers and babies through their practice which for many Doulas is unregulated.

The article focuses on and highlights that Doulas only train for perhaps two to four days, have no formal qualifications and their practice is not regulated, whereas Midwives train for six years in Spain, and for three years full time in the UK and achieve an academic degree alongside vocational training to ensure that their practice is up to scratch. Their profession is also regulated, whereas some doulas are not.

Midwives argue that Doulas may receive poor training or give inappropriate or concerning advice to women and may not recognise pregnancy conditions or symptoms which could occur during labour which may put the health of the woman and the health of the baby at risk. Doulas argue that they do not need so much training as they are only giving support and guidance to the woman and tending to her emotional needs rather than giving hands-on medical care.

I always think it’s interesting to see how midwives view the practice of Doulas. As a Doula myself, I have experienced negativity from midwives through my own practice who perhaps view me as unqualified to be offering support during the birthing process and think that I may think I am a replacement for the midwife. Happily, I am well aware of and very happy in my role as a lay supporter, who is present in addition to the midwife.

I feel that I am in quite a unique position as a Doula because I am also an NCT Antenatal Teacher with a University Foundation Degree in Antenatal Teaching and facilitating adult education. This means that I have spent three years studying and learning about pregnancy, labour and birth in the context of facilitating antenatal classes, but also have had to virtually swallow a midwifery textbook (myles or mayes anyone!) at the same time for indepth exams on the clinical side of obstetrics and so I feel that my obstetric knowledge is very sound.

I have also undertaken one of the UK’s only University based Doula courses which is a nine month course with an OSCE exam and university certificate qualification at the end of it. All of my training and practice is regulated through the National Childbirth Trust and the midwifery depts of the associated universities. I am also provided with the relevant insurances and mandatory CPD and training days, which I have to attend to maintain my licences to practice.

With this training, I would feel equipped to recognise concerning signs or symptoms throughout pregnancy and birth and indeed I always encourage clients who mention things (such as excessive scratching or feeling reduced movements) to seek guidance from a medical professional during pregnancy. In my practice as a Doula I would feel confident to recognise the meaning of differences in colour of the water during labour, or highlight the need to move to hospital if a woman’s behaviour or external symptoms were concerning, or understand what accelerations or decelerations of a heartbeat may indicate for example. Some argue that medical qualifications and knowledge are not mandatory for a Doula as she is not giving medical care.

However, I do feel that the Doula should have a basic understanding of the mechanics of Pregnancy and Childbirth, and be able to recognise when birth is straightforward and everything is going swimmingly, and when causes for concern may arise which need to be considered. Some doula courses offer doulas an excellent grounding in preparation for their role, and others are more focused on teaching women to run their own business to make money for themselves and the umbrella organisation rather than concerned with being knowledgeable about looking after women beyond holding their hand, stroking their hair and arguing with the midwives (ok, I know I’m being stereotypical here).

I have to say that I know of some fantastic Doulas who have no formal qualifications, but have spent many years practising, have undertaken study days and been responsible for their own learning whether formally recognised or not, and who I would feel completely comfortable with trusting to look after me during labour and birth as I have faith in their knowledge, expertise, and most importantly, their ability to know their own limits and boundaries and know where their role ends and the midwife’s begins.

I have also met other Doulas who have literally done the three or four day course and whom I would be extremely concerned about hiring as my own Doula due to their lack of knowledge, their lack of integrity and their need to put their opinions and wishes ahead of the woman and the midwife. I help interview at a university for those wishing to study the midwifery BA course to become midwives and I have interviewed quite a few Doulas who have viewed their Doula work as an avenue into midwifery. There have been a real mixed bag of Doulas, some who I can tell are a great asset to the birth experience of a woman, and others who have literally done their course and started practising without the knowledge and understanding of midwifery and the ability to put their wishes to one side, both of which I feel are vital to support a woman during labour. One person I interviewed couldn’t tell me how many different stages of labour there are, what the midwives role in the birthing process was, even suggesting that it was her role to get involved in the medical side of childbirth and “help” mum catch the baby on her own whilst the midwife sat back – which of course is not the Doulas role at all. I would of hated to be the woman who had hired her!

The best Doulas are able to work with midwives and the women to bridge communication and get everyone working cohesively as a team together, rather than alienating the midwife, or getting their back up. They also recognise their own limitations and see their role as offering emotional and practical hands on support rather than medical practice whilst also empowering the woman to feel confident in asking questions about her care.

So why are some midwives so concerned about Doulas being involved in childbirth? Do they make things unsafe for the women and their babies?

It is these radicalised stories we hear of Doulas who perhaps encourage free birthing without a midwife, or placenta encapsulation or eating the placenta (which is actually shown to have nutritional benefits for mum) or staying at home as long as possible before transferring, or ignoring the midwife’s advice which worries midwives about the Doula profession. Through the practice of a small minority, you can see how midwives might get the impression that Doulas practice unsafely and jeopardise the practice of the midwife because they perhaps encourage women to birth unsafely and do things which midwives would not feel comfortable to suggest.

I don’t think that Doulas encourage women to do this. I would say that they enable them to do this. Doulas are in the unique position of enabling women to think outside of the box and allowing them to express their hopes for labour and birth. They can listen to and help facilitate the woman’s wishes for birth such as perhaps birthing at home in their own back garden under the big oak tree, or waiting as long as possible before cutting the cord once the baby is out, or counteracting suggestions to start a syntocinon drip in favour for another hour of active mobilisation. They can hold a woman’s hand and rub her back whilst she wanders around the hospital grounds in labour, they can encourage her to get into water if that’s what her body is telling her to do, and hold a space to help a woman and her partner to have privacy during the labour process. Whilst bound by their own codes to practice safely, they are not bound by the policies and procedures midwives are by the NHS and this can be a scary thought for midwives, that there is someone in the room who should know the labour process, but is not on the same page as the midwife perhaps when it comes to limitations and time constraints which within the NHS are steeped in litigation and the fear of a malpractice suit.

Having said that, this also comes with a caveat as my own practice needs to be safe. If a woman came to me and told me that she was planning on freebirthing and wanted me there, I would be exploring her reasons behind it, and trying to find a way for her to build bridges with health professionals and coming up with solutions to enable the baby to be born with the presence of a midwife, whilst I want to enable her wishes to be fulfilled, personally, I would not feel comfortable being present at a birth where I knew that the woman wanted me there as a substitute for a midwife (although some might argue which is better, a doula with no midwife, or noone at all?)

With the policies and procedures which most midwives are bound by, through working for the NHS, it is natural to see how when asked to practice outside these constraints of the NHS “box” and bend the rules a little, some midwives may feel worried, scared, or apprehensive about suggestions which a Doula makes such – even little ones such as perhaps asking for a woman to sit on a ball or remain upright whilst being continuously monitored, not laying down to push, delaying syntocinon, or not performing a VE as she suspects the results may make the woman feel disheartened. When midwives tell Mum that she has option A, or perhaps option B to consider in a certain situation, and Doulas come up with option C which is a perfectly viable option but which would be outside of the NHS “box”, it is only natural to see how midwives may feel that Doulas put them in a compromising position because they remind them that as autonomous practitioners, they should be considering all of the options and putting the best interests and the wishes of the woman at the centre of their care, rather than being bound by NHS procedures to start a synto drip because a woman isn’t progressing quickly enough, or continuously monitor a woman, or make her lay down, or make her birth on the delivery suite because she perhaps has a high BMI or is considered too “old” to give birth.

Recently I facilitated a very interesting discussion with a group of Student Supervisors of Midwives who aired their frustrations about wanting to do the best for their women and consider those outside of the box options, but 99% of the time having to forgo their autonomy in favour of doing what their employer, the NHS wanted for fear of being penalised, or accused of practising unsafely, or simply because it just wasn’t the “done” thing at their hospital to accommodate choice for women, despite the recommendations of the Francis Report and others.

Fear of litigation and malpractice affects the midwives practice, as does the culture and environment in which she works, which on the outside verbalises choice for women and puts the woman at the centre of her maternity care but behind closed doors, disempowers the woman and constricts what she is “allowed” to do as soon as she enters NHS territory. Most Doulas try to enable women to claw back some of this “power” of choice, whilst at the same time treading the tricky line of not wanting to upset the midwife by suggesting things she may not feel comfortable with. It is a really tricky balance as midwives are often not happy having their practice questioned – who is?

Having a doula in the room can put the midwife on edge as she knows that she is having to perhaps cover all of the bases and she may be asked to do things outside the realms of her comfort zone such as allowing the woman extra time before intervening during the labour. Indeed at the last hospital birth I attended, upon my arrival, they sent the Supervisor of Midwives into the room to look after the woman as the midwife present did not feel comfortable about the thought of having a doula in the room. It’s easy to see why midwives may feel wary of Doulas.

On the contrary, other midwives feel very comfortable with having doulas present and perhaps also welcome their presence as they know that the woman has a constant support who will be “useful” where some partners may not be, and perhaps their job is made a little easier. But where does this leave the practice of those unregulated Doulas who may hinder the birth process? Studies have shown how kind words and one-to-one emotional support can improve birth outcomes for women, and that having a Doula does improve outcomes for women because they can offer that one-to-one support that midwives working within the NHS cannot. However, Doulas should be clear and explicit that they are not medical trained. Their practice has limits and boundaries just as the midwife does and she should hand over to a more experienced colleague if she does not feel confident in her practice.

Whilst most Doulas are accommodating woman’s choice in a safe and knowledgeable way, there are others who are on a stereotypical “natural childbirth crusade” and who may encourage women to give birth in unsafe or compromising situations. There may be those who question a midwife’s practice but do not have the knowledge or skills to back up their questionning.

Personally, I believe that a good Doula should have medical knowledge of pregnancy and childbirth. She should know the process inside out, be aware of complications that can arise and what different signs and symptoms mean. Whilst she doesn’t have to be the Einstein of birth, she should feel confident in knowing when a suggestion by a health professional is just NHS policy and the research is contradictory, other options are available or the midwife needs encouragement to support the woman even though the situation is “outside the box”  vs. where a suggestion is necessary or even life saving. She should feel comfortable in supporting a woman through all birth scenarios, and also feel confident in negotiating the woman through the different stages of labour by using a range of different techniques and suggestions in different scenarios to offer the woman the emotional support needed to birth her baby, whilst also including the partner throughout the journey.

Personally I don’t believe that a three or four day course can achieve this, although I do think it is a good stepping stone and that backed up by further support, training and study, it can be a good basis for being a doula. Doulas can play a vital role in helping women throughout the birthing process and beyond as they have the time to spend with the woman that often the midwife does not. Doulas need to feel confident in their own knowledge of the birthing process, and be sure that the information and suggestions they are offering to women are evidence based and do not put women and their babies at risk.

Although the article suggests that Doulas “encourage” women to eat their placenta, I would suggest that they “facilitate the woman’s choice” to eat it, which is not considered dangerous. The Royal College of Midwives (RCM) says that there is not enough evidence for the organisation to “either support or not support” eating the placenta, however lots of anecdotal reports from women suggest that it does have health benefits. Many other mammals eat their placenta, but culturally it is seen more as a lifestyle choice. The concern comes around the hygiene of the preparation to consume it, rather than actually digesting it.

Those choosing to hire a doula should feel confident in her training, in her ability to support them though the birthing process in an autonomous way in any environment, and feel confident that she will work with the midwife throughout the birthing process, whilst also offering suggestions of alternative safe practices within childbirth and facilitating the woman’s choice at the centre of it. A good doula should be maintaining links with her most local unit. She should be attending groups such as the labour ward forum or MSLC, and be working in partnership with midwives as a lay professional.

If you are considering hiring a Doula, ensure that you ask her about her training, how she would support you in different care settings, what are her views are on epidurals, assisted birth, caesarean birth etc. Ask her how would she would help facilitate your care in those tricky situations when you may want to go against the NHS “norm”, what is her relationship with midwives, how does she maintain her own knowledge about labour and birth etc.

In response to the article, I think that regulation for Doulas can only be a good thing and is something which many doulas have called for to stop those who practice in a concerning way from giving the others a bad name. Doulas working under the NCT and Doula UK are working for self-regulated bodies, although the training courses vary greatly.

If you are a midwife working with a doula, I would ask you to question how she can help you fulfil your role during the birthing process rather than perhaps seeing her as a threat or an enemy to the birthing process. If you are considering hiring a doula, I would suggest interviewing two or three to get a feel for who you would prefer to have present at the birth.

Are you a midwife? What has your experience of having a doula present at the birth been? 





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