I love and adore doulas.  I think they are indispensable, and I wish every mother had access to an awesome doula.  Having a doula lowers your chances of a C-section by a whopping 28% (!) and support like what they provide was recently included in the 2014 guidelines published by the American College of Obstetricians and Gynecologists as “one of the most effective tools to improve labor and delivery outcomes.”  Doulas are, without question, a critical part of the birth team.

What some moms don’t realize, though, is that doulas can’t say every little thing that’s on their minds, and they have professional standards that may preclude them from talking to you like you are a best friend.

My own doula and I have had more than one conversation about why she didn’t warn me about my own provider—someone who I now know has a reputation for not following through on promises to patients.  “But I asked you!” I’ve said to her.  “Why didn’t you tell me?”

She has explained patiently, each time, that she gave me the information I needed to make my own decision.  What I wanted from her—to say, “Oh, Cristen, you need to switch providers right now!”—is not something she would ever say to a client.  Instead, she gave me specific questions to ask.  She encouraged me to talk to my provider about my wishes and pay attention to the conversation, to trust my instincts, and to be honest with myself about whether or not I thought my provider was really going to follow through with what she’d promised.

Sure enough, I ignored the red flags.  And sure enough, things came to a head with that provider.  Finally, I switched care at 41 weeks, 6 days pregnant.  (But that’s another story.)

Since then, I’ve talked to hundreds of consumers and doulas and have sat with them for hours in talks around the country, from Los Angeles to New York.  Every single group of birth professionals said the same thing about their clients—sometimes in tears of frustration: “They want us to protect them and we can’t!” and “My job is to support them, but it KILLS me that I can’t tell them what they’re up against.”

This isn’t to say no doula has ever said or done these things.  Some have and do.  And, in fact, the evolving role of the doula has become a hot topic in the doula community and a discussion I’m excited to see happen (in fact, one doula organization released a statement in response to this article–check it out here).  But, you should know that, traditionally, the role of the doula has been pretty strictly defined by professional organizations and most doulas stringently adhere to their code of ethics and scope of practice.

So, I’m going to tell you three things your doula can’t.

1. They won’t bash your provider.

I don’t think I’ve spoken to a single doula who hasn’t expressed enormous frustration at not being able to say to a client at one time or another about that client’s doctor or midwife, “Hon, run away as fast as you can!

In fact, it’s a frequent topic of discussion among doulas—what to say when you know a provider practices a certain way (say, has a 50% episiotomy rate) to a client who has been told otherwise by that provider (“I only do them when they’re medically necessary!”).  Doulas can certainly advise you to get that provider’s statistics, but their job is to facilitate you getting information and to support you in making your own decisions.  If you are convinced your provider is the right one for you, your doula is not going to try to convince you otherwise.  With this in mind, pay attention to what your doula is saying, and what she’s not saying.

The fact of the matter is, there are a good number of providers out there who market things they are not willing to deliver—and doulas usually know who they are.  The most common scenarios?  Natural birth (suddenly, at 38 weeks, you discover you are “required” to have continuous monitoring; during birth, you’re told you must be on your back, in bed), vaginal birth after Cesarean (there’s even a term for when a mom is told in late pregnancy her provider is no longer supportive of her plans: bait & switch), and saying they will attend your birth when, really, it will be whoever is on call.  We also take for granted that midwives will practice like midwives, when, in reality, sometimes they can take a more medicalized approach to birth or are pressured to practice a certain way because they are being supervised by obstetricians or monitored by hospital administration.

Why do doulas take this approach about your provider?  For one thing, doulas are truly committed to you making your own decisions.  They’re not supposed to tell you what to do!  It’s out of respect for you and your journey that your doula won’t take over your birth and your decisions.  Neither do they want to instill seeds of negativity or fear in a woman who has already chosen her provider and, who, ultimately, will stick with that person no matter what her doula tells her.  Doulas won’t intentionally create negativity or fear.  They want to be your safe place.

Another reason is that doulas have a fine line to walk between best serving their clients and maintaining good working relationships with local care providers.  This isn’t merely self-serving on their part, because their good relationships directly serve you, too. Imagine, for example, you’re a parent who tells everyone your child’s teacher is a bully, and she shouldn’t be teaching because she’s so incompetent… and the teacher finds out what you’ve said.  What happens when your next child gets ready to move up to that class?  How do you think that teacher is going to treat him?

More and more, though, I’m seeing doulas move toward a more proactive approach here.  They might say to you, “I’m sorry; I don’t work with that provider.”  That’s their gentle way of saying, “I can’t watch that person ruin your birth.”  Take heed.

2. They can’t protect you.

Doulas are not bodyguards, spokespeople, or substitute medical providers.  They won’t interfere with hospital staff, nor will they say, “Hey!  Stop right there!  That wasn’t on her birth plan!”  Sadly, I would guess there are very few doulas who have not seen a client receive a procedure that the client did not properly consent to, which makes this part of their role all the more difficult.

Your doula can and will say, “Dr. X has scissors in his hand.  Do you have a question for him?  Is there something you need to say right now?”  Your doula can’t and won’t step between you and the scissors.  (Sound like an extreme example?  The 2006 Listening to Mothers survey found that 3 out of 4 women who received episiotomies did not give consent for the procedure–see the full report here.)

This is a very difficult place for doulas to navigate in a system where some care providers regularly fail to obtain permission for routine procedures and practices.  But just because certain providers are willing to overstep their own bounds, it doesn’t give your doula permission to overstep hers.

3. They can’t make your decisions for you.

There’s actually an important concept here that is the backbone of the doula philosophy: You are the decision-maker in childbirth—not your doula, your husband, your doctor or midwife, or anyone else.  Those others are there for assistance, support, and expertise, not as your authority.  It’s as wrong for your doula as it is for anyone else to make decisions about your body or your birth.

Handout from 3 Things Every Parent Needs to Know About Hospital Birth (http://www.birthmonoopoly.com/3-things)

Click image for more (Handout from 3 Things Every Parent Needs to Know About Hospital Birth)

This concept often comes into play when a doula is seeing someone being told they need a procedure for a reason that is not evidence based–or for no real reason at all.  This goes for a slew of common practices that still happen every day in American hospitals.  Just one example: a leading cause of C-sections is so-called “Failure to Progress,” which has been estimated to be misdiagnosed as much as half the time.  As Evidence Based Birth succinctly puts it: “many women are being incorrectly diagnosed with failure to progress, when what they are experiencing is actually normal, and could be more aptly named ‘failure to wait.’”  As for inductions, we see things like “big baby” and “low fluid” and “going past the due date” all the time—all non-evidence-based reasons to have potentially risky inductions.  Similar reasons are used with regard to vaginal birth after Cesarean (VBAC) by anti-VBAC providers and institutions.

But your doula isn’t going to tell you what to do.  She can only guide you towards the information you need to make your own decisions—and if you are going to step back and let your care provider make your decisions, that’s a decision you’ve made, too.

What else do you need to know?

I cover more of the most common “unknowns” in my new online class 3 Things Every Parent Needs to Know About Hospital Birth!  In just 30 minutes, you’ll get must-know information about routine care in hospitals, birth plans, hospital policies, hospital consent forms, and your most basic rights.  Watch the short video and get more info here.  Doulas, this is a great tool for you to use with clients, too, to spark discussion about how you’ll work together to navigate routines and policies!

Enrollment is open until July 2015 only.  Sign up here if you’re interested in 2016 enrollment.

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Version 2A former communications strategist at a top public affairs firm in Baltimore, Maryland, Cristen Pascucci is the founder of Birth Monopoly, co-creator of the Exposing the Silence Project, and, since 2012, vice president of the national consumer advocacy organization Improving Birth.  In that time, she has run an emergency hotline for women facing threats to their legal rights in childbirth, created a viral consumer campaign to “Break the Silence” on trauma and abuse in childbirth, and helped put the maternity care crisis in national media.  Today, she is a leading voice for women giving birth, speaking around the country and consulting privately for consumers and professionals on issues related to birth rights and options. 

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Free handouts + monthly-ish updates from Birth Monopoly: click here