All About Doulas
What is a doula?
A doula is a labor support professional who “mothers the mother” during childbirth, as well as during the prenatal and postpartum periods. Birth doulas provide support to pregnant women prenatally, through labor and birth, and in the early days postpartum. Postpartum doulas provide in-home services to families, typically lasting from three weeks to three months, or longer with special circumstances. Some doulas combine the birth and postpartum roles into a complete service package, thereby offering continuity of care throughout the childbearing year.
Doulas are non-medical care providers. Their role is limited to educational, emotional, physical, and logistical support. They do not provide clinical care such as taking blood pressure or checking dilation in labor, nor do they give medical advice. A “doula” who offers vaginal checks at home in early labor, for example, may be offering a service that you find desirable, however her role is more accurately described as “monitrice” (a clinical role which falls somewhere in between the doula and the midwife role). Postpartum doulas are not “baby nurses,” but a nurse may offer in-home care to postpartum families. Likewise, a “doula” who “prescribes” homeopathic or herbal treatments to support healing also may be offering a service that you value, but she is operating outside of the scope of practice of the doula professional.
All doulas provide information, emotional support, and comfort measures such as massage, hydrotherapy, and enhanced relaxation. Doulas enjoy providing attention to expectant parents and getting to know their clients prenatally. By the time you go into labor, your doula has become a trusted friend and mentor. During labor and birth, doulas feel privileged to be present and helping at such a sacred and joyful event. Postpartum doulas simply love hanging out with new moms and their babies! Your doula is there to support you in your choices and to provide concrete physical and logistical support. Doulas do not take the place of dads, partners, or other family members who want to help you. Their job is to facilitate everyone’s optimal participation at your birth, as well as to provide support to the entire family through the postpartum recovery and adjustment period. If you are a single mother, your doula can serve as your primary support person so that you are never left alone in labor.
A selection of services provided by birth doulas
- Nutritional counseling
- Tips for coping with discomforts of pregnancy
- Preparation for birth
- Assistance in creating a birth plan
- Support at home in early labor
- Comfort measures in labor
- Massage
- Suggestions and support for positioning in labor
- Continuous support throughout labor and birth
- Troubleshooting for difficult births
- Facilitate communication and informed decision making with your health care providers
- Support for dads and partners
- Natural birth coach and advocate
- Support for VBAC (Vaginal Birth After Cesarean)
- Cesarean and post-cesarean support
- Respect for the bond between mom and baby in those tender early hours
- Encouragement and skilled support to breastfeed
- Postpartum home visit(s)
- Community resources and referrals
A selection of services provided by postpartum doulas
- Breastfeeding support
- Newborn care
- Comfort measures and support for the mother’s physical recovery
- Shopping, errands, meal preparation
- Laundry, light cleaning, household organization (not housecleaning)
- Sibling adjustment support (not babysitting or nanny services)
- Depression screening and referrals
- Education on infant topics
- Community resources and referrals
Shifts worked by postpartum doulas vary. Some may do overnights, others may stick to the weekday hours when their children are in school, and so on. Expect a typical shift to be from three to four hours, though some doulas may work an eight-hour day. There are no rules – it is up to you and your doula. Typically, support is more concentrated in the first two weeks and then gradually the family weans off of doula support. However, in special circumstances such as multiples, preemies, babies with special needs, or moms suffering from postpartum depression, postpartum doulas may be involved over a longer period of time.
Before hiring a postpartum doula, consider whether or not you are really seeking a nanny for your other children or house cleaning help. If those are your primary motivations, then you should hire a nanny or house cleaner and will probably come out better financially by doing so. Another option may be to start out with a doula for the first couple of weeks while mom is recovering physically, adjusting emotionally, and may be in need of breastfeeding support, and then transition towards hiring a nanny later (say, in the case of twins or multiples).
What is a certified doula?
A certified doula is one has chosen to complete a certification process through a doula or childbirth association such as DONA International, Association of Labor Assistants and Childbirth Educators (ALACE), and others. While certification processes differ, certification generally means that a person has: (1) completed a proscribed training program, (2) documented a minimum level of hands-on experience with positive client evaluations, (3) completed reading requirements, (4) agreed to work within the Scope of Practice as defined by the certifying organization, and (5) paid her membership and certification processing fees. The process certainly guarantees a minimum level of training and experience for providing doula services. It is an effort to professionalize the traditional role of the female support person at birth and during postpartum.
Is certification important?
It depends upon who you ask. From the consumer perspective, good worth of mouth in the community, or a recommendation from a trusted friend trumps certification any day. Certification is no guarantee that your doula encompasses the personal qualities of patience, humor, compassion, integrity . . .
Some insurance companies may reimburse for doula services. Ask your doula if any of her clients have been successful in getting reimbursement or partial reimbursement for her services. As the doula profession grows, we expect increased success for insurance reimbursement and if/when this happens, it is likely that certification will be required.
What are the benefits of doula support?
There have now been several studies on the benefits of continuous labor support on labor and birth outcomes. Laboring women who are supported by doulas have lower c-section rates, lower instrumental delivery (forceps and vacuum extraction) rates, and are less likely to use epidurals or pain medication than women who do not have doula support. These women also have shorter labors, have more positive childbirth experiences overall, and are more likely to breastfeed. Furthermore, the newborns of these women have higher 1-minute and 5-minute Apgar scores.
Postpartum doulas can have a strong impact on early parenting success. The evidence shows that women who use a postpartum doula have increased rates of breastfeeding, decreased rates of postpartum depression, decreased incidence of maternal re-hospitalization for complications postpartum, a stronger bond with their newborns, greater self-confidence in their parenting abilities, and increased understanding of newborn care.
Is it appropriate to have a doula if my partner will be at the birth?
Yes! The doula’s role includes supporting the laboring woman and supporting her partner. Your doula should be able to work alongside your partner and/or other family members and show him/her/them how to best support you. If you and your partner have taken childbirth classes, the doula can remind you of techniques you learned in class and provide guidance through the physical and emotional challenges of labor support. Your doula can provide your partner with breaks, facilitate communication with your care providers, and, in short, be an excellent addition to your birth team.
Is a doula appropriate if I have an epidural?
Yes! Many women are unsure of whether they will want an epidural (or know they will want one) prior to going into labor. While you should ask your doula if she is comfortable working with women who choose a medicated birth, the role of the doula is not to critique your birth choices but rather to support you and ensure that your wishes are respected. A doula can improve your chances of having an unmedicated birth if that is what you prefer, but she should also be able to provide you with non-judgmental emotional and physical support in the context of a medicated birth. Women who choose to use an epidural during labor can especially benefit from a doula during the pushing stage, as this stage can take longer for medicated births due to the decreased physical sensations intrinsic to the use of epidurals. In addition, because the medications used often make mothers and babies drowsy, it is extremely helpful to have a doula during the immediate postpartum period so that she can support early breastfeeding efforts. Epidurals provide pain relief, not emotional support!
Is a doula appropriate if I am having a planned cesarean birth?
Yes! Although women having planned cesareans do not experience labor in the same way as women planning natural births, a doula can still be helpful to prepare you for the experience. Your doula can help you learn about the choices that you have in the context of a cesarean birth and can also provide emotional support before, during, and after the surgery. Because recovery from a cesarean often takes longer and is more complex than recovery from a vaginal birth, a doula can be an asset to parents during the postpartum period. A postpartum doula can help with newborn care, provide breastfeeding support, prepare meals, and help take care of your home while you recover from surgery.
Charlie’s Story
Read the story of one mother who received postpartum doula support from the Doulas Care program.
Hiring a Doula
How can I find a doula?
Check out our Directory of Practitioners and see who is available in your area
If you do not have success there, try the following websites:
- DONA International
- Michigan Midwives Association Directory
- Birth Network Directory
- My Nanny Rocks (for postpartum help)
- Childcare Network (for postpartum help)
In addition, some home health care agencies have tried expanding into the postpartum doula market, so if you are not having success otherwise, you may want to explore that possibility.
If you live in southeastern Michigan and cannot afford to hire a doula, call Doulas Care at 734-332-8070. This non-profit organization matches volunteer doulas with low income women and their families. Services are free and include both birth doula and postpartum doula care. Some bilingual doulas are available through this program.
If your husband is unavailable to support you because he is away on active duty in the military, there may be free help available to you through various state and/or national organizations providing free doula care to the wives of military personnel. Operation Special Delivery is one such organization.
What do doulas charge for their services?
Because individual doulas determine their own rates, there is no precise standard to determine how much you should pay for doula services. Some doulas have a set rate, while others may use a sliding scale so that they can provide services to clients at a range of income levels. Expect doula rates to vary based on level of experience, additional services provided, geographic area, and certification status. In general, doulas charge from $400 to $1000 per birth. Keep in mind that this fee generally includes prenatal and postpartum visits and compensates the doula for the days and weeks she commits to being on-call for you in addition to paying for her services at the birth itself. Postpartum doulas generally charge from $15 to $30 per hour. Presumably, the more experienced, and therefore more skilled, doulas are the ones charging the higher fees, with less experienced doulas starting out at the lower end of the scale.
How to hire a doula
- First, screen to see who is accepting clients around your due date.
- Ask how much the doula charges and what services are included in her fee.
- If the answers to the first two questions lead you to want to pursue the possibility of hiring this person, then you could ask for some time for a short phone interview.
- Ask about her level of experience, whether or not she has been formally trained as a doula, whether or not she is certified, and what her philosophy of care is (i.e., what are her thoughts and experience with breastfeeding?). You might want to know if she is a mother herself, what she thinks her biggest strength as a doula is, what she enjoys most about her work, etc. For a more complete list of questions, see below.
- An enthusiastic but inexperienced doula with whom you feel a warm rapport may be preferable to a more experienced doula with whom you feel uncomfortable, for any reason. Trust your instincts. This is all about getting your needs met.
- As you move through this process, you will likely have narrowed down your selection to one or two people with whom both you and your partner (if any) should meet in person and interview. Some doulas may charge a small fee for this interview, applying it towards your bill if you hire her, but otherwise non-refundable.
- Ask for and check references. The most useless doula in the world is the one who is unreliable (if she doesn’t answer her phone when you are in labor, who cares how skillful or “nice” she is?). Doulas who have created good word-of-mouth about their services are likely to endeavor to ensure that you too are a satisfied customer.
- Check credentials. If the doula claims to be a DONA International certified doula, you can confirm her certification by using the DONA online doula locator. I expect other certifying organizations have a similar system.
- Does the doula have an agenda (my way or the highway)? If so, is her agenda congruent with yours? Try to think of a few questions before the interview that are designed to get at the answers most important to you. Have your partner articulate any questions or concerns he/she may have as well. In the end, make sure you hire someone who can provide non-judgmental support for you and your family. You don’t want to have to hide your diet pop cans when your doula comes to your home, nor apologize for a medicated birth if those are your choices. (I’m having a hard time letting the diet pop statement stand, because it’s SO bad for you, but I hope that makes my point about non-judgmental support . . . I would not be the doula for you if you wanted me to bring you your diet pop in labor, or at least, I would be very challenged in this regard.)
- In the case of hiring a postpartum doula, many couples find themselves in a rather urgent frame of mind (“Can you start today?”). Consider starting with a one-week commitment from your doula with the possibility of extending beyond that time frame. If integrating a stranger into your home proves more stressful than helpful, you may have chosen the wrong doula.
Sample questions to ask a prospective doula
The best way to choose your doula is to consider the fact that the doula will be present at your birth, or providing in-home support at a time when you may feel vulnerable. Ask yourself with whom you (and your partner) feel the most comfortable. Just what are you looking for? What helps you when you are feeling stressed? Information, humor, kindness, massage, a flexible attitude, a good listener? Are you looking for a mother figure or more of a big sister? The personality and beliefs of your doula may well be more important than any other individual factor. If you choose to interview one or more doulas, it can be helpful to ask the following questions. In the final decision, trust your gut. A less experienced, uncertified doula may resonate better with you than the most experienced doula in town.
- How long have you been in practice as a doula? How many families have you served?
- What training have you completed to prepare you for this role? Are you certified?
- What is your philosophy about your doula work and its purpose?
- Are you a mother yourself? (This may or may not be important to you. Doulas who are not mothers themselves may have more time to focus on you and your needs, while doulas who are mothers themselves certainly will bring an added dimension of understanding to their care. On the other hand, experienced mothers may be more opinionated about the “right” way to do things, based upon their own beliefs and experiences. Look for someone capable of flexible, non-judgmental support or, if she has an agenda, make sure it’s the same as yours!)
- Do you have experience with other clients whose situations are similar to mine (first-time mothers, natural/medicated birth, same hospital, home births, older mothers, single mothers, VBAC moms, etc.)?
- How much do you charge? Under what circumstances would I receive a refund?
- What is included in your fee (prenatal/postnatal visits, phone support)?
- Do you work with a backup doula? If so, will I be able to meet her?
- Do you have any references from families for whom you have provided services that I can check?
Additional questions for birth doulas
- How certain are you that you will be able to attend my birth? Do you have any other commitments during that time period?
- How do you picture yourself supporting me and my partner during the birth?
- Do you provide labor support in the home for women planning hospital deliveries?
- Do you only work as a birth doula or can we also hire you for postpartum work if needed?
Additional questions for postpartum doulas
- Are you available for overnight help, weekend help, daytime help, etc.?
- How much experience do you have with providing breastfeeding support?
- What services do you provide or exclude? (For example, some doulas may be willing to do some sibling care, scrub out a bath tub, or walk the dog, while others may not. Really think through what it is that you need and then ask questions to determine if the doula can meet your needs. In some cases, parents might be better off hiring a babysitter or nanny if their concerns revolve around balancing the needs of a two-year-old and newborn twins.)
- Do you have any add-on services (such as bringing meals, sharing information regarding alternative therapies for healing, massage, etc.)?
All About Midwives
In the State of Michigan, consumers have great freedom of choice regarding midwifery care. If you are just beginning on a path of looking into your choices regarding birth attendants and place/setting for the birth of your baby, then these choices may be a little confusing. We will attempt to clarify here.
Certified Nurse Midwives (CNMs)
CNMs are credentialed through the American College of Nurse Midwives (ACNM). They are RNs with additional Masters-level training in midwifery. Nurse midwives can attend births in hospitals, free-standing birth centers, and homes, though they are primarily found working in hospitals. You may find nurse midwives in solo practice, small group practices of two or three midwives, or large practices of ten or more who rotate being “on call.” Large practices may assign one midwife who you see for prenatal care, but it is potluck at your birth. Most insurance companies will reimburse for their services. They work with doctor back-up and abide by medical protocols that may mandate consultation with, or transferral of care to, the back-up doctor in some circumstances. CNMs, for example, cannot be the primary care provider for women expecting breech or twin deliveries. Ask your prospective nurse midwifery service about their protocols regarding transferral of care and insurance coverage.
Direct-Entry Midwives
Direct-entry midwives — also known as “lay,” homebirth, or traditional midwives — are an eclectic group in Michigan. There is no government oversight regarding licensure or certification of direct-entry midwives in this state. The practice is considered “a-legal” in that it is neither prohibited by law nor sanctioned by the state. Compared to some states in the country where direct-entry midwifery is against the law, or other states where it is licensed and regulated, the status of Michigan direct-entry midwives allows for maximum consumer choice regarding birth attendants.
Direct-entry midwives may attend homebirths or out-of-hospital birth center births. Typically they work with low-risk, healthy women who desire a normal, non-medicated birth. A complete homebirth or birth center service package should include prenatal care, attendance at your labor and birth, and postpartum care, with phone consultations as needed.
Direct-entry midwives may participate in a national certification process through the North American Registry of Midwives (NARM). A midwife who has completed experiential skills training and passed the NARM exam earns the Certified Professional Midwife (CPM) credential. This credential is used as the requirement for licensure in 22 of the 24 US states which license direct-entry midwifery. Some direct-entry midwives may have a nursing background and RN credential, but practicing midwifery is outside the scope of nursing licensure. Direct-entry midwives who lack credentials may nevertheless be highly experienced and qualified, and have sound reasons why they have chosen not to pursue the CPM credential. Most direct-entry midwives are apprenticeship trained and self taught. Some have attended midwifery schools or undertaken a home study course. “Lay” midwife technically means a person with no experience or training who attends births.
Theoretically, there are no complications that a birth center midwife can handle without medical backup that could not also be handled at home. While a birth center may convey a greater sense of safety, this, in and of itself, is an illusion. However, if the birth center attendant is more skilled, that is not an illusion. When emergencies happen at a homebirth or in an out-of-hospital birth center, 911 is called and the woman and/or baby is transported to the nearest hospital. In Michigan, physicans do not back up direct-entry midwives in the same sense that they back up nurse midwives. However, ERs cannot refuse care and many direct-entry midwives have friendly doctor “back up” to the extent that a physician may order necessary tests for the midwife or be willing to consult with her if needed.
Insurance & Fees
As a rule, insurance companies do not cover out-of-hospital birth attended by direct-entry midwives, but there are some exceptions. Women on Medicaid or covered under HMOs will not be able to get reimbursement for direct-entry midwifery services. Check with your insurance provider regarding the feasibility of homebirth coverage. Midwives should also be able to tell you the providers with whom their clients have had success in gaining reimbursement or partial reimbursement. You should expect to pay the midwife’s fee up front, out of pocket, and then gain her help in generating a proper receipt suitable to submit to your insurance provider for reimbursement. Midwifery fees in Michigan currently range from $1,000 (very low-end for midwives attending rural, religious, or Amish communities) up to $4,00 or more. If you have a high-deductible insurance plan, it is quite possible that the midwife’s fee would equal the amount of your co-pay for a hospital birth. Healthcare Spending Accounts (HSAs) or “Flex” accounts can be used as well.
Choosing a Midwife
The practice of midwifery is not the practice of medicine, and medical procedures such as pitocin induction, epidurals, and surgical procedures should take place only in hospitals. Some homebirth midwives may be skilled in working with herbs, homeopathics, and nutrition. Prevention is a hallmark of good midwifery care, and supporting, rather than interfering with normal processes often prevents complications. Midwives can vary in their approaches to midwifery care. For example, some midwives may choose to use dopplers to listen to fetal heart tones, while others may use the low-tech fetoscope. Just because a midwife attends births in a birth center or at home does not guarantee her practice of midwifery is non-interventive.
Clients should interview midwives carefully to find the approach to care that is a good match for their needs. How many births has she attended as the primary midwife? (This should be distinguished from “years in practice” which is essentially meaningless; i.e., someone can claim 25 years’ experience, but have very limited experience as a primary midwife. Hint: Most midwives worth their salt will have a ready and precise answer to this question and it should not be rounded off to the nearest hundred. Do you trust the claim she is making?) Which potential complications can the midwife handle? How is she prepared to handle them? What percentage of her clients give birth with their perineums intact? What are her practice protocols for pre-term or post-term babies? Under what circumstances will she transfer care to medical backup? What percentage of her clients end up with a hospital transport? Is water birth an option? The answer to these questions will vary, depending upon the individual midwife and the practice setting. By asking the right questions, you should be able to find the midwifery practice that is most closely in alignment with your beliefs and preferences.
Careful interviewing of prospective midwives is in order! Ask around. Good word of mouth about a birth center or homebirth practice is important. Midwives who are dishonest, irresponsible, or unskilled get weeded out pretty quickly, but there may be a few out there who are mis-representing their level of training and experience. Create your own list of questions prior to interviewing midwives, a list that reflects your values and priorities, and hire someone who has her act together. Trust your instincts AND check her references/credentials.
Midwifery Model of Care
The Midwifery Model of Care is based on the fact that pregnancy and birth are normal life processes. It includes:
- monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle;
- providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support;
- minimizing technological interventions; and
- identifying and referring women who require obstetrical attention.
The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.