What Doulas Do

My doula, Zoe Krylova, took these gorgeous photos at my mother blessing.

We remind folks through pregnancy, birthing and parenting that what they are experiencing is normal, when it is. We accompany them and hold their hands if their experience veers from normal. We are not care providers, but we do offer deep, thoughtful presence and we certainly are individuals who care.

Holly Powell Kennedy, Varney Professor of Midwifery at Yale University writes that doula-attended birth, rather than serving as a throwback to some romantic image of the past: "represents an evolution to an educated, supportive companion who knows how to support the childbearing process..." Whether trained through a certifying body or self-taught, doulas are educated.

My doula training in 2010 changed my life. At the time I was on a leave-of-absence from a Chinese Medicine masters degree program which had me feeling drained and at my physical limit. My mentor was an acupuncturist and also a doula who was pregnant with her second child: “you should enroll in the Natural Resources doula training and attend my home birth,” she invited. I did. There were a dozen students in my class, led by a home birth midwife named Abigail Reagan who is a powerhouse. I went in thinking that I would be the only non-mother but the class was evenly split between folks who had given birth and those of us who had not. We met weekly and got to know one another on a deep level. We studied birth physiology, learned about the protocols and practices of local care providers, watched birth videos and challenged our assumptions meeting after meeting. One weekend we gathered with an additional teacher for an intensive workshop in guided meditation, massage and other comfort measures. My ten week training wrapped up the month before both the first birth I was honored to attend and my wedding (the next day)!

The summer after my training I began attending births as a low/no-fee doula. The midwife who orchestrated our training maintained and operated a list of newly trained doulas who had completed her course, written papers on six of her assigned books and worked with three families for low or no fee and received reviews from said families. She helped me find my first several clients, but I had other incredible support as well. Doulas are masters of lifting one another up and I benefited enormously from this lineage. Doulas also pay it forward.

My aunt helped found a non-profit in the Bay Area called Helping After Neonatal Death. The families I served who had lost babies at term or shortly after birth and who went on to welcome subsequent children were extraordinary teachers and some of my most cherished clients. With those families I acknowledged deeply the thinness of the veil, how tied up birth and death are, and through their loving inclusion of me in their experiences welcoming new babies I felt moved to attend the first several Spirit Babies ceremonies in the Bay Area. Spirit Babies recognized the beauty and loss inherent to miscarriage, stillbirth and abortion - honoring every experience in its holiness. I brought that ceremony with me to Charlottesville twice alongside other birthworkers. Doulas laugh and cry along with you.

A seasoned doula and wonderful yoga teacher named Britt Fohrmann took me under her wing and I was her back-up doula for several families, which afforded me the opportunity to attend prenatal appointments with her and see how she worked. I had a similar chance to learn from someone extraordinary when I began to work with Cindy Whitman-Bradley. Cindy eventually invited me to join her and Audrey Muto in a doula collective called (Re)Birthing, through which I established my enormous love and appreciation for collaboration, sharing stories and skills, processing and clarifying my art in this field. Over the years in San Francisco (after Audrey left to attend Yale Midwifery school) we in (Re)Birthing Collective were lucky to work with Elizabeth White, Cheri Solin and Melissa Berg, who was my very own acupuncturist/mentor/the first woman I saw powerfully bring a baby into the world - he will be 8 in a few months! Doulas love to learn from one another, from clients, and doulas love staying in touch with their doula-babies over the years.

The Bay Area Doula Project training I completed in 2011 was another milestone. Through that program I was certified to support folks through miscarriage and abortion and I am marvelously grateful for the connections that persist among that first BADP cohort. Many have gone on to advocacy work, to midwifery, to parenthood, and we all honor that we are experts in supporting any pregnancy through any choices and any outcomes. Doulas stay by your side no matter what.

My postpartum doula Dianne Bearinger and birth doula Zoe Krylova

I moved to Charlottesville at the end of 2012 and since then have more than doubled the number of births I’ve attended. Sadly the proportion of home births has not been the same (in the Bay Area about one third of my clients had their babies outside of the hospital system) but I am moved by the variety of options birthing folks have even in this small community. There are two hospitals, two birth centers, and home birth options among providers. In Virginia I've attended two workshops related to trauma and birth, and a  course on the essentials of prenatal massage. 

During my first few years here, Charlottesville Doulas gathered on a monthly basis to compare notes, support one another in matters of business, to read and present on topics of interest to us and to share birth stories. That group is less regular these days, but I now co-coordinate EMERGE Doula Circle, which holds monthly peer review sessions as well as continued education presentations. Doulas are passionate about staying up-to-date with research and literature as well as social activism. Doulas network, organize and share knowledge to support one another and birthing people.

In their book Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, Christine Morton and Elayne Clift explore the history of childbirth and the social factors that have led to doula work as a profession.  They quote Judith Walzer Leavitt who said, "Ever since birth moved out of women's homes and into the hospital, birthing women, individually and collectively, have been trying to recapture some of what they lost, at the same time maintaining what they have won." Doulas know this balance well. 

For three years I was an editor with the all-volunteer staff of SQUAT Birth Journal. We held two conferences and had a large readership of birthworkers and families all over the country. The radical inclusivity that drove SQUAT is in my blood. I am thrilled in our community to have the Department of Health Improving Pregnancy Workgroup (which I attended regularly before my daughter was born) and Sisters Keeper, which is a branch of Mother Health International working to address the disgusting disparities in maternal and birth outcomes for People of Color in this region. Doulas care deeply about the future of humanity.

Giving birth changed my practice as a doula as well. I have long talked about the broad spectrum of experience around birth and how each birth drops a brand new pin in the array, but I somehow did not expect that after attending around 60 births my own daughter could completely surprise me...but of course she did. Her birth story is for another day, but I am enormously grateful for the experience of my own sheer power - as my own advocate, as a recipient of midwifery care, as a ferocious beast, as my most tender, beautiful self. To this day, 20 months after I gave birth, my attendance at other births is nuanced by the fact that I still breastfeed around the clock. I have taken breaks from supporting families to pump breast-milk. I have had to let go of seeing someone actually push out their baby because I absolutely had to call in my back-up. I am properly humbled and that is important. Doulas are realistic.

What do doulas do? We hold space. We validate and normalize. We recognize your power. We honor and share in the sacredness of your experience. By our presence we remind care providers that this is your birthing, your family, your life. We do a certain amount of physical support via position changes, basic massage and sometimes acupressure, but I see much more of my work on the energetic, informational and narrative planes.

What Doulas Don't Do (and why doing the DON'Ts made me a better doula)

What's the T on what doulas DON'T do?

One of the most meaningful ways that I can show respect to my clients and ensure that I maintain a reputation of professionalism and safety is to adhere to a very clear SCOPE OF PRACTICE.  I love this work!  I am so excited to further my training as a midwife and continue caring for birthing people!  As a doula and future midwife, I find that it is important for me to be very clear about how I function differently in these two roles.

In preparation to write this blog post, I have realized that I find myself in very few conversations about scope of practice.  We talk about the things we DO as doulas during our interviews.  Surprisingly few people ever ask about what we DON’T DO!  It seldom comes up in discussions with other doulas.  I assume that this is because there really isn’t much to talk about.  From my perspective, the boundaries are so very clear there is not a whole lot left to explore amongst the Bright Birthing team or in professional gatherings with other doulas.  

I LOVE the Evidence Based Birth article about the evidence on doulas.  I share the article with all potential clients to provide research to back up what we already know: having a doula can make for a better birth experience!  This blog post, however, is focused on what doulas don’t do.  Knowing our limits is just as important as knowing how to use comfort measures and positioning, create a calm environment, and provide emotional support.  Perhaps we will elaborate on what doulas DO do in a future blog post?! Because what doulas DO and DON’T DO is so clear in the Evidence Based Birth article, I’m gonna use their words instead of my own to clarify the boundaries of our work -- efficiency for the win!

Here’s an excerpt from the article Evidence on: Doulas, taken from https://evidencebasedbirth.com/the-evidence-for-doulas/

What is NOT included in doula support? Doulas are not medical professionals, and the following tasks are not performed by doulas:

• They do not perform clinical tasks such as vaginal exams or fetal heart monitoring

• They do not give medical advice or diagnose conditions

• They do not make decisions for the client (medical or otherwise)

• They do not pressure the birthing person into certain choices just because that’s what they prefer

• They do not take over the role of the partner

• They do not catch the baby

• *They do not change shifts (although some doulas may call in their back-up after 12-24 hours)

*YOUR TEAM DOULAS DO CHANGE SHIFT, but you don’t get a stranger, you get your caring, compassionate, skillful OTHER doula.  YAY!

Seems pretty simple and straightforward, right?!  NO cervical checks, NO monitoring heart tones, NO medical advice.  Of particular importance to me is that I do not see my role as BEING the voice of my client.  I believe it is my role to AMPLIFY the voice of my client.  I am very clear within myself, with the Bright Birthing team, and with potential clients that I am not in this work to project my own ideals about birth onto anyone else’s experience.  My job is to educate and empower.  My job is NOT to make decisions for birthing people.  

Now, I think there’s a lot to be desired in modern maternity care.  So, for the record, choosing to support my clients, empower them to make decisions, encourage them to be educated consumers, and walk with them through the maze of machines and medications in no way means I’m giving a high-five to the madness of hyper-medicalized birth and our country’s very not evidence-based approach to all things labor, birth, and child care.  But I REALLY, REALLY so very strongly believe that healthcare consumers will be the drivers of change.  And I REALLY, REALLY so very strongly believe that birthing people will drive change when they are informed, educated, empowered and having their own experiences that make it so very clear that the system IS NOT SERVING THEM.

Ok, so why am I on about this?  Well, it occurs to me how VERY important it is that birthing people understand that a doula who might be offering services such as cervical checks and fetal heart tone monitoring has stepped outside of the boundaries of doula work.  If you’re interviewing a doula who offers those services, it would be important to ask what other qualifications and experience allow the doula to perform those tasks safely.  Then, it would be necessary to clarify that those still ARE NOT things that doulas DO, so it would be important to hash out exactly in which capacity that provider intends to serve you.  See where I’m going here?  INFORMED CONSUMER-VILLE!  When birthing people, doctors, midwives, doulas, and whoever else is involved as a pregnancy support team are all on the same page about who does what, the whole system works better!  AND clients are safer!

A couple of years ago, I learned that an organization based in Richmond, ToLabor, was including vaginal exams and fetal heart tone monitoring in their doula training.  I was shocked! Alarmed!  Concerned!  How could they?!  Then, I read their website FAQs (http://www.tolabor.com/about-tolabor/faqs/) about the training and it made so much sense!  On the surface, this was so contrary to everything I understood about the doula role.  But ToLabor wasn’t teaching doulas to perform vaginal exams so they could send them out into the world of doula work to harm clients and put themselves at risk for some serious loss of credibility within their communities.  ToLabor offers student-doulas the VOLUNTARY opportunity to perform vaginal exams and listen to fetal heart tones so that they can become more comfortable with touch, better understand pelvic anatomy, and get a real sense of their clients’ vulnerability.  I actually kinda think it’s brilliant.  They also have anyone who comes through their workshops sign a scope of practice agreement and make it completely clear on their website that performing vaginal exams and checking fetal heart tones is NOT part of a doula’s work.  

I never attended a doula training workshop.  When I became pregnant with my first babe, I turned into a bit of a self-study maniac on all-things pregnancy, labor, birth, and parenting.  I read so much.  I was never without a book on one of those topics, well into my son’s first year.  Then I started midwifery school and began the process of becoming a Certified Professional Midwife.  So, I learned to be a doula by learning to be a midwife and through my own yearnings to learn about pregnancy, birth, and child care.  I’ve participated in voluntary vaginal exams.  I’ve measured fundal height.  I’ve checked fetal heart tones.  I’ve assisted with something like 75 prenatal appointments, during which I checked urine screens, checked the pregnant person’s vitals, and palpated pregnant bellies.  But learning to do these things as a midwife, did NOT ever give me the impression that they were part of my work as a doula.  

As a result of participating in voluntary vaginal exams, I understand the importance of talking to pregnant people about what is happening during pelvic exams and why the information gained might be helpful.  I understand pelvic anatomy because I have felt the ischial spines, and the ovaries, and the pubic arch with my very own short little fingers.  I’m more comfortable with touch because I’ve measured, palpated, and assessed.  Really, it is hard for me to imagine my doula practice without the deeper understandings I gained from being a midwifery student.  So, I can appreciate ToLabor’s approach.  I see the value in learning about things that are OUTSIDE of the scope, to better inform the work that is done WITHIN the scope.  And I trust the people doing the work to know the boundaries.  

If you ever have questions about the limits of the doula’s role, feel free to give us a shout!  You might also check out the DONA (very credible doula organization) statement on the doula scope of practice, which can be found at https://www.dona.org/wp-content/uploads/2017/08/COESOP-2017-FINAL-Birth.pdf.  

We’re also happy to answer questions about our training and experience any time-via email, fb messenger, or at our regular gatherings!