Birth Doulas: What Are They & How Do I Choose One?

Meet Lindsay Wolff, PhD, CLD(ToLabor), CBE

 A local doula & mother of two who made the switch from Dr. to Doula. She quit her job in academia to pursue midwifery studies and start Birthing Matters Doula Services. As a certified professional birth doula, she offers professional services that are customized to fit your family’s wishes. In addition to continuing education in the doula field, Lindsay is currently working toward becoming a Certified Professional Midwife. Lindsay is a skilled and experienced doula who is deeply connected to the area resources for pregnancy, birth, and postpartum care. Her clients describe her as warm but with a lighthearted demeanor, gentle, and calm (and they say she gives a great massage). I have asked Lindsay to write this post about Birth Doulas to shed light on some questions that come up frequently for expectant clients. Lindsay's commitment to her clients and professionalism with fellow birth keepers made her an obvious choice to answer these common questions! 

Birth Doulas: What Are They & How Do I Choose One?

By Lindsay Wolff,  PhD, CLD(ToLabor), CBE

What is a doula?

While the term “doula” originated from the Greek term meaning “woman who serves” or “servant,” the term has evolved to mean a support person who works with people and families in their reproductive journeys, lending physical and emotional comfort, reassurance, information, and presence. There are many different types of doulas- those that specialize in birth, postpartum, pregnancy loss or termination, adoption, and surrogacy - among others. Some doulas choose one or more specialties and others, like full spectrum doulas, bring the doula model of care to people through the full spectrum of pregnancy experiences.

The research behind doulas:

A thorough review of research (totaling 21 trials involving more than 15,000 women) on continuous support in labor concluded that continuous physical and emotional support through labor was associated with fewer medical interventions and a slightly shorter duration of labor, among other clinically relevant outcomes.[1] That review included any continuous support, not just that offered by trained doulas.

When one looks further at the research and separates out the support offered uniquely by doulas, the outcomes are even more staggering! In a benchmark study [2] that looked at the effects of doulas and partners working together, researchers found that combining a supportive partner and a doula significantly lowered the pregnant person’s risk of Cesarean compared to having a supportive partner alone. For instance, that research found that the cesarean rate for these first-time parents was 25% in the group with a partner only, and 13.4% in the group with a partner and doula. Further, among people being induced, the Cesarean rate was 58.8% in the group with a partner only, and 12.5% in the group with a doula! Lastly, fewer people in the doula-supported group requested an epidural (64.7%) compared to those without a doula (76%).

So, what is it about doulas? Why are the outcomes so different?    What can a doula offer?

I think that the single most important thing a doula offers is what is known as primacy of interest. A doula’s primary responsibility is to the birthing person—not to a hospital administrator, nurse, midwife, or doctor. While there are some hospitals that employ doulas to work with certain populations, the majority of doulas are self-employed or work for a business that is separate from the hospital. This means that doulas are free to help you understand what options may be available to you that may not be part of the standard of care due to financial bottom lines, need for beds, etc.; but, also it means that they are dedicated to staying with you and aren’t held to scheduling, hospital budgets, etc. Did you know that nurses, OBs, and midwives don’t stay with you through the whole process? I think that this is something that many first-time parents don’t fully realize. Without a doula, there are long stretches of time in hospital births that parents and their partners are left alone without extra support.

Lastly, doulas have a less streamlined view of birth than many hospital support people. Doulas are not only there for emotional and informational support; they also provide invaluable physical support in labor by suggesting and supporting positions, using physical techniques to encourage baby’s descent and cardinal movements through the pelvis, and to encourage the person in labor to release tension through massage, breathing, acupressure, and more.

3 Common Myths and Truths of Working with a Doula:

1. Myth: Doulas are for people who want a low or no-intervention birth. I can’t tell you how many times I have had clients say some version of “well, my provider said that if I end up opting for an epidural that a doula isn’t necessary.”

Truth: An experienced doula is well equipped for supporting you through your birth whether you are planning an unmedicated birth or not. In fact, all plans aside, birth is about being in the moment and not every step is predictable. Doulas are there to help you navigate. The providers that think doulas are unnecessary for people who opt for anesthesia just really don’t have a good understanding of all the support that a doula provides. Not only are there still a lot of position changes that we can do with an epidural in place, doulas make sure all of your questions get answered, support your partner, and help facilitate discussions with your providers while maintaining your birthing space as a calm and comfortable environment. Also, the comfort measures don’t stop with an epidural in place -massage, helping with pushing positions (yes, I’ve even seen people get up and squat with an epidural (when they have felt like they had the strength to do so), bringing cold washcloths for your head and neck during pushing, and the list goes on!

Doulas are also of immense support in the OR during a cesarean birth (if the anesthesiologist lets us in)! Helping you find focus on each other and navigating options that can help your birth be as special and beautiful as you envisioned your birth being, protecting your space, providing neck and shoulder massage, facilitating skin-to-skin in the OR, and being a continuous support for your birth team are just a few of the ways a doula is of value to your cesarean birth. When not permitted in the OR, a doula helps settle you into recovery and bonding with your baby, helps with breastfeeding, comfort, and makes sure you and any other support people have their needs met.

2. Myth: Doulas make the support of partners or other family members less important.

Truth: Doulas really enhance the experience for the entire team. First off, partners or close family members are an absolutely irreplaceable asset to a laboring person. They are a source of comfort and love that cannot be replaced. I recently heard an analogy by Gena Kirby (aka the rebozo lady), a doula trainer, that sums this up so well: try hugging your partner, mother, sister, or best friend and notice how you feel; now, hug your doula. Not the same feelings, smells, hormones (oxytocin!!!) or familiarity.

A doula spends a lot of time getting to know you and your partner or other support people and learning how they can best support you all through their this experience. With a doula’s knowledge of birth and your family’s knowledge of you, we make a phenomenal team.

3. Myth: Doula = Midwife

Truth: This is an easy one...Midwives are professional care providers that are trained in supporting expectant parents in pregnancy, birth, and early postpartum. During these periods of time, Midwives are ultimately focused on the clinical health of  you and your baby. During birth, they are focused on charting and clinical tasks. Doulas are focused on you and your emotional and physical comfort and helping you navigate decisions in your birth so that you feel that you have all of the information to make informed decisions in consultation with your care provider. While doulas are providing you emotional, physical and informational support, they are not a care provider.

How to find a doula and what questions to ask them during an interview:

There is a doula that fits every personality, budget, philosophy and experience level. A good place to start browsing is DoulaMatch, an online database of doulas, searchable by availability and location. Even better, ask someone who you know and trust if they have a referral- whether this is a care provider or a friend, ask them not only if they know a doula, but in what context and why they recommend them. If it is just a business associate or they met them at a networking event, then they don’t really know them as a doula. Find someone who has had a personal experience with someone or ask a care provider that has had clients that have worked with a trusted doula. When you find someone that appeals to you, send them a message and set up an in-person consultation!

What is important:

●      Finding someone who makes you feel comfortable, calm, and supported.

Whether that is someone who has attended hundreds of births or less than a handful, ask yourself how comfortable you are with this person and if you would be comfortable opening up to them about your concerns, excitement, and needs.

●      Accountability and trust.

This is a huge one for me. Since anyone can practice as a doula, we are relying on an individual’s integrity to be honest about their experiences, to adhere to the scope of practice as a doula, and to stand by a code of ethics. Does certification hold you accountable? Yes. Certification also shows that your doula has demonstrated knowledge and competency.  Do I think certification is required to have knowledge, competency, and integrity? Absolutely not; however, there are people, as in any profession, that will inflate their self worth and credentials to get hired. I feel strongly that if a doula lies about their credentials, they are stripping parents of the informed consent that our work stands for.

●      Your doula’s relationship with other perinatal health workers.

Not only should a doula be connected to their community to be able to provide you with quality referrals and resources, they should also have a great relationship with other doulas. This is a field of community over competition; it’s what ensures our families are being supported by the right person, not just the person who happens to be available or whose price is right.

What’s not important:

●      Your doula’s social media presence.

If your doula is posting live updates from a birth, they aren’t respecting your privacy, no matter how anonymous they are trying to keep the post. Also, a good reputation is built through attending births and word-of-mouth, not by blogging about yourself and your accomplishments. Your doula’s Instagram following has no bearing on your birth.

●      Your doula’s personal birth experiences.

Whether your doula has given birth themselves or not, their stories are not relevant to your own. This birth is about how this person can best support YOU! Some people want to hire a doula that has had children of their own, as they have first-hand knowledge of the process and the sensations, and for others that is not a priority. Either way, the decisions that they made or plan to make in their births are not relevant to your own experience.

Questions to ask:

Who/what organization did you train with and why did you choose them?

What are your fees?

Do you have a backup doula? Can I meet them? How often are they used?

How many prenatal and postpartum visits do you do?

Can I email, text or call you with questions? When in pregnancy does that support begin?

Do you have experience with birth complications and/or unwanted outcomes? What does your support look like in those situations?

Have you attended home births (if planning to give birth at home)?

When do I first call you? Is it OK if it’s in the middle of the night?

When do you join us in labor and how long do you stay? Where will you meet us?

How do you work with partners or other support people?

What is your philosophy and your “style”

Do you have any special strategies for labor support and pain relief?

How long do you stay after birth?

Do you have experience with breastfeeding support? 

If interested in regular postpartum support, ask if this is something they provide or refer out for?