Why Do I Need a Doula if I’m Using a Midwife?
By Jan Mallak, 2LAS, ICCE-CD-CPD-IAT, CD-PCD(DONA), CPD(CAPPA)

Try to imagine what it was like 200 years ago to give birth. Woman had their babies at home, they were surrounded by familiar sights/sounds/smells, changing position and moving around was normal, pain medication was not really an option, the laboring mother was attended by other women … stop right there! Let’s look at the history of childbirth and explore the ‘who, what, when, where, why and how’ associated with labor support.

Since the beginning of humankind, WHO has been supporting women through childbirth? Other women! Just as men taught their sons how to provide the “necessities” for the family, women had another way of ensuring survival - MOTHERING. It is that special gift that begins at conception, grows during pregnancy and comes to fruition at birth. Birthing happens to both mother and baby – it is a right of passage that bonds them forever. The journey is an important one so why not use a guide? This is where the doula enters.

WHAT have women been doing for other women down through the generations? Helping them, guiding them, supporting them, teaching them, role modeling for them, nurturing them and assisting them transition into being mothers. And, the woman-to-woman support was before, during and after the birth. This is a phenomenon that has all but disappeared in today’s world. This is where the doula re-enters. She provides the “wrap around” care just like her ancient sisters did.

An expectant mother can choose from a variety of health care providers to “catch” her baby. One great option is midwives – nurse or direct entry. Midwives catch babies at home, in freestanding birth centers or at hospitals. This gives the woman a variety of choices when deciding on the best option for her. Plus, midwives take fewer patients, spend more time with the mom during appointments, encourage sharing in the woman’s own care, respect her wishes, provide moms with resources, have better outcomes than obstetricians and the list goes on.

As a result, some mothers limit their thinking to just the midwife (and nurse) when considering the women she wants at her birth. Do you think women 200 years ago restricted attendance to just a midwife and her assistant? Where would her friend, neighbor or family member fit in? So nowadays, families have been invited into the birthing room to help and witness the birth. But, they haven’t really been trained to help and can get emotionally swept away. Especially if it gets long, hard or becomes an emergency. This is where the doula particularly comes in handy.

Doulas do not provide medical care, advice or interpretations. This is the major difference between doula and midwife. So, their schooling, training and responsibilities are different. Tips, tools and techniques to keep labor moving and to help women cope by using their natural resources are the doula’s main goals. This is done by providing physical, emotional, informational and spiritual support plus mediation. Reducing the need for interventions is often another role of the doula. This is one area where support from both the doula and midwife can help the mother avoid routine IVs, monitors, epidurals, etc. Working in conjunction by blending doula/midwifery skills and knowledge will certainly benefit the mother.   

Doulas constantly learn from interacting with midwives and visa versa since each has a unique role thus a unique perspective. If an opinion is offered and the suggestion works, this is cause for celebration for the client/birth team and not the time for thinking that anyone was usurped by another. Learning is life long and goes both ways many times. Being philosophically in sync with one another is another huge benefit when it comes to using a doula and a midwife. They consider birth to be a natural event not a medical one. All listen, care and are most assuredly the mother’s advocates!  

Most doulas do not work for the birthing facility so that frees them up to practice objectively. Some do and may have certain restrictions or limitations. Midwives practicing at facilities must abide by their policies. Because doulas often go to many different birth settings, they may be more up-to-date on differences regarding each place’s general philosophy, procedures, protocols, etc. Sometimes this information about other’s “management” techniques opens up new possibilities with their client’s care providers or facilities. Plus, mixing with a variety of care providers and staff is a form of continuing education for doulas. Staying current, correct and conscientious regarding birthing practices in her community is part of a doula’s responsibility.    

The doula provides the social support (emotional, physical, informational and spiritual) while the midwife provides the medical support. Granted, a midwife can also offer social support. But, she usually cannot guarantee that she will be with you constantly. Other clients, other duties, her shift ending or a hot meal and a quick nap may take her away from you. After all, you want her to be well rested to catch your baby! Home births better ensure constant attendance by the midwife but then roles further differentiate the midwife from the doula. Midwives function as doctor, nurse and doula. That’s three roles! How can she possibly do them all at once? Especially when the birth turns medical or the baby is actually coming. Many repeat moms hire doulas to help with Second Stage because they feel support was lacking at that point last time because the midwife was busy (as was the nurse). The medical care is a huge part of the birth equation so to not be distracted by other roles is critical. Plus, the doula can see to the midwife’s needs – get her things, make sure she has food and drinks, make calls for her, bring family up-to-date, etc. In other words, assist her with non-medical aspects in any way the doula can while helping her maintain her stamina. This is another reason why the doula is so valuable … to everyone.

 WHEN a woman needs support is another factor to consider. Midwifery appointments are usually monthly until the end. A doula connects with a mom and builds a rapport over the months. The touch and trust relationship they develop is unique and special. It is not meant to take away from the midwife’s relationship with the client. It is a different kind of relationship. Midwife literally means “with woman.” A doula is a ‘personal handmaiden’ since the mother is queen for a day! The definitions themselves point out the difference. Some groups have several midwives in practice together. This can lead to preferences among health care providers or unfamiliarity with some of them. It never fails – the one she never meets or likes the least will be the one to catch her baby! The doula is that constant throughout the trimesters who was chosen to attend the mother no matter what. She speaks regularly with her doula, they work on a Birth Vision together and spend time together going to appointments or a LLL meeting or just out to lunch. The client knows she can call her doula just if she’s having a bad day or because she felt the baby hiccup for the first time. The doula educates the couple and facilitates their decision making about what kind of birth they want. Most of those things would probably not be expected of a midwife.

WHERE a mom needs support is also worth thinking about. Before the birth, doulas go to appointments, classes, La Leche League meetings, sonograms, external versions, baby showers, blessing ways or belly castings, etc. Doulas can begin their labor support at home and then go to the birth center or hospital as things progress. Immediately after the birth, the doula assists with bonding and breastfeeding. Many stay for several hours to ensure that the family feels comfortable and confident before leaving. Most midwives are generally not available for that extra length of time either.

A doula comes to the home after the baby arrives to check on mom and the family. She brings a birth report and gift for the baby. She offers suggestions on getting organized, staying healthy and transitioning into parenthood. The doula often helps with breastfeeding and can help if depression starts to creep in. She’s in touch with the family more than a midwife because of sheer numbers of clients each is caring for at any given time. Doulas limit their clients so they can really maintain their close contact with the mothers. This is part of why moms who have doulas experience less postpartum depression, have better success with breastfeeding and generally report having a more positive birth experience.  

So, WHY  does a woman need a doula if she’s using a midwife? The simple answer is because they have different roles within the birth team. They certainly overlap and that’s a good thing. Doulas are happy to take a break and have the midwife rub mom’s back or help her to the bathroom. It’s nice to grab a quick meal knowing your client is in very good hands with the midwife. Doulas are also good at sharing the workload since we do it with family as well. We often model roles and then encourage family to take over. Plus, there is plenty of work to go around in that room to keep the mother safe and satisfied.

HOW labor support is provided is the last consideration. Penny Simkin, co-founder of Doulas of North America created a chart comparing aspects of a mother’s labor support as provided by doctor, nurse, midwife, doula and partner. It measures things like uninterrupted physical presence, understanding of woman, advocacy of mother’s wishes, freedom from other obligations and comfort measure knowledge among other things. Although doulas and midwives run neck in neck when being compared, the doula has slight advantages over even the midwife. The midwife may not be free from other obligations, may not be able to continuously support the mother and may not know the mother well. None of those would be an issue with a doula who has developed a rapport with her client and is devoted to her and only her.
 
That is why it takes a team. If a woman feels her birth team should include a midwife and a doula then that is the right set of circumstances for her. When ‘asked’ if a doula is needed if using a midwife, she will often be told that the midwife or nurse will fill that role. If a midwife is ‘told’ that a doula has been hired, she will probably be pleased. If decision making is left up to the mother by offering her all options, she will be able to make an informed choice. Doulas are expected to follow a code of ethics and standards of practice which clearly states that they are not to place their personal agenda on the mother. When asked about birth options, doulas must provide all choices without trying to influence the mother’s decision. That is the professional way which is also truly woman-centered and SHE is what it’s all about.