I’m just home from the AWHONN Michigan conference on Mackinac Island, where I was invited to speak about ways labor and delivery nurses can improve birth.
As part of my main talk, I addressed nurse-doula relationships, as I usually do when I have the honor of working with nurses. I asked them if they ever saw doulas speaking for clients. Most of the hands around the room went up. After my talk, two nurses immediately made a beeline for me to tell me about serious challenges they were having with a local doula, who speaks for her clients at every birth. It’s definitely not the first time I’ve heard it. Whenever I train nurses, they bring up this issue of doulas speaking for our clients again and again. This is a problem, doulas. A big one.
Now despite the ranty title I gave to this blog post, I do realize I’m not the ethical arbiter of the doula profession. Doulas can choose for themselves how to interact with clients and staff at a birth. But let me make the case for why speaking for your clients is almost always a terrible idea.
If you’re a DONA International doula, you’re out of scope.
The DONA International Standards of Practice and Code of Ethics address this issue head on. It's a great guide for helping us think through our responses.
From the Code of Ethics:
Rights and Prerogatives of Clients. “The doula should make every effort to foster maximum self-determination on the part of his/her clients.”
I’d argue that if you’re speaking for your clients (even if you’re repeating what they told you previously that they wanted), you are interfering with maximum self-determination.
And from the Standards of Practice:
“Clients and doulas must recognize that the advocacy role does not include the doula speaking instead of the client or making decisions for the client. The advocacy role is best described as support, information, and mediation or negotiation.”
Well there you go. In black and white, DONA doulas don’t speak for their clients.
What about your certifying organization? Leave a comment below to share what your organization says about this issue. It’s my sense that most doula organizations agree on this point. Am I right or wrong?
You're stealing your client's power.
I think most doulas who speak for their clients are honestly trying lift up their clients, honor their wishes and help them have a great birth. I get it!
It’s true that doulas do remind our clients of what they wanted for their birth, and we speak up when things are straying from the plan. Many dozens, maybe more than 100 times, I’ve said something like this at a birth:
“Megan, I know you didn’t want Pitocin for your birth. Do you want to ask Dr. Smith about pros, cons and other options before you decide?”
Yes. This question reminds Megan of what she wanted, alerts her that things might be about to stray, reminds her to ask questions, and reinforces that it is her decision whether or not to use Pitocin as a tool during her birth. It lifts her up to advocate for herself — the client has the power. If Megan didn’t ask all the questions that I think might be helpful, or if I know of other options that weren’t mentioned, I also might chime in with a question or two to help bridge the communication between her and her provider. That’s totally within the doula scope and, I would argue, empowering.
What if instead, the doula said, “No, she really doesn’t want Pitocin. I think we’re going to get this labor going on its own.” This is the kind of thing nurses tell me happens all the time.
It’s tempting to think that people are too vulnerable in birth to speak for themselves. That’s rarely the case. With good support, and even when their voices shake, I’ve heard so many women dig deep to find their power, and speak for what they want. I'm always there to back them up, but unless they are unconscious or otherwise compromised, our clients can speak for themselves.
Even when our clients want to give their power to us, it’s never ours. It’s a hard thing when a medical professional asks a question, and our client looks to us for our opinion. From what nurses tell me, this seems to be when doulas are most often stepping in to speak for the family. I have opinions in these moments, and I’m sure you do too. But it’s never our place! I don’t want that power.
Consider for a minute what this scenario might look like if your client has changed their mind. Yes, Megan might have told me before her birth in the strongest terms that she didn’t want Pitocin, but maybe now she’s thinking that it could be a good option. She might be looking to me for an opinion, reassurance, confirmation or to talk her out of it. If I offer an opinion or speak for her, it all but takes away the option for her to make her own decision, free from anyone’s influence. She’s now thinking about my advice, and also my judgement if she goes in another direction. I’ve already spoken for her, so she’d have to directly contradict me in order to change her mind — “Actually, Jessica, I think I’d like to give it a try.” That’s pretty awkward.
Doulas, you are not the person giving birth, and you are not trained as a medical professional. It seems pretty clear that you should not be the one speaking up here. If you’re ever in doubt, ask yourself in the moment, “Who has the power right now?” If the person with the power is the doula, the nurse, the provider or anyone except the person giving birth, that’s a problem.
It puts you at risk for liability.
Again, I don’t want the power. If the doula is making the decisions, that comes with responsibility and liability. Our profession is protected from the most serious liability risks precisely because we are non-medical. If something goes wrong and the doula has made decisions for the client, that can all come rushing back to the doula in the most serious, risky ways.
I remember one of my mentors telling me years ago, “Jessica, we [doulas] know just enough to be dangerous.” For real. For those doulas who really want to be involved in the medical side of birth, please, go get trained! We need you as a nurse, a midwife or a doctor. After you’re educated, you can give all the advice you want, and you’ll also carry the liability for those (now fully informed) recommendations.
You're going to raise tension with the staff.
Medical professionals get irritated when doulas speak for our clients. “It’s like it’s her birth every time,” one nurse told me this weekend about a doula, “not the patient’s.” Another nurse said, “I was really worried about this mom’s safety, and here was the doula telling me we couldn’t do what we all thought needed to be done. It wasn’t just a preference issue, it was about safety. It would have been one thing if the client was saying no, but it was the doula.”
I don't blame these nurses for being irritated. They should be.
And their irritation will last not just for this birth, but into the next time they see this doula. Sometimes, it might even extend to the next doula they see, too. If the doula had just lifted up the client to speak for themselves, most of the tension would likely be avoided.
Sometimes we need to do things within our scope of practice that annoy the staff. There have been times that I’ve spoken up to remind someone that they have a choice, or to alert them to something that was about to happen without their consent, to the great irritation of a nurse, doctor or midwife. But that’s part of my job, and clearly within my scope. I can handle that irritation, and because we have respectful and collaborative relationships at other times, the staff and I are usually able to work through it with mutual regard. And I am absolutely not afraid to speak up in the face of obstetric abuse, which I have done and would do again in a heartbeat. But why bring on that frustration for something that is clearly outside of our scope, and that is potentially disempowering to our client? It’s just not worth it.
We’ve seen a big evolution of doula-hospital relationships in my home community over the past dozen years. There was a time many years ago when my relationship with one practice in particular was pretty rocky. Whenever I walked into the room with a client, the tension immediately went up. I could feel it and I’m sure my clients did too, which is one of the reasons I decided to stop doing births with that practice (which is now out of business).
Tension and adrenaline are not good for the hormones of labor. That means that when we’re fostering unnecessary conflict with the staff by speaking for our clients, we might also be doing direct harm to the client’s labor progress. Even beyond that particular birth, the tension can extend to your next client’s birth, and the client after that, especially if speaking for your clients is a pattern for you. That tension can also unfairly extend to other doulas who do stay within their scope, just because they too are “doulas.”
Today, after lots of relationship building with our hospital staff, when I or one of the doulas in my agency walk into a hospital room, we’re usually greeted warmly. Sometimes we even get a hug. The client relaxes and oxytocin flows, knowing their team is ready to work together to help them have a great birth.
Rocky relationships with staff are bad for business.
If all the other reasons haven’t convinced you to avoid speaking for your clients, maybe money will. The most successful doulas I’ve known get referrals from doctors, midwives and nurses. That’s not likely to happen if you’re regularly speaking for your clients. Actually, they might warn clients against working with you. And if you end up with practices that won’t work with you or a hospital that bans you from attending births there, that’s really, really bad for business.
Now hear me on this. I’m not ever going to sell my doula soul, and I don’t think you should either. I will always advocate for my clients (within scope), and I will always speak up when confronted with obstetrical abuse. That’s my obligation as a professional and as a human being.
But in this case, it turns out that what’s within my scope and empowering to my clients also happens to be good for business. Win-win-win. I’ll take the business boost as a bonus reason not to speak for my clients.
So if you’re feeling me now on this issue, and you agree that you’d rather not speak for your clients, what’s a doula to do instead?
It can take some practice to master the doula’s advocacy role. In my experience, it can be tempting to speak for a client in a few common situations. Here are the circumstances I’ve seen, and some suggestions on how to handle them.
Something is happening quickly, and your client has told you they don’t want it.
I think well-meaning doulas sometimes speak for their clients in these circumstances in the interest of time. For example, a cord is about to be clamped, and the client wanted to take a physiologic approach. It would be easy to say, “She wants to wait to cut the cord,” and that might be true.
I’ve been occasionally caught in this situation, and I can empathize that it’s a mouthful to quickly say, “Kiara, it looks like Dr. Smith wants to cut the cord right away, did you want to talk about that first?” Instead, on this particular issue, you can be pre-emptive by checking in with your client between pushes, especially if you know their provider prefers early cord clamping. You could say, “Kiara, do I remember right that you wanted to keep the cord intact until it’s done pulsating? This would be a great time to talk with Dr. Smith about it.” In this case, you’re connecting my client with their provider — a bridge of communication.
Another strategy you can effectively use if things are moving very quickly (and not for an emergency reason), is to say directly to the medical professional, “Oh, I think she has some preferences on that. Could you please check with her first?” I like to think this also prompts the nurse, doctor or midwife to remember to be their own best professional selves, seeking out permission and consent (or refusal) instead of just plowing ahead out of habit.
The nurse or provider asks you directly what the client wants.
This has happened to me a number of times, and it always take me by surprise. When I’ve asked nurses about it, they usually tell me it’s because they’re used to other doulas telling them what a client does or doesn’t want. It’s a fairly easy response for the doula here: “I’m not sure, let’s ask.” Another reply you can give is, “I know she had some thoughts on that, why don’t we check in?” If it’s something mentioned in your client’s birth plan, you can also refer back to that document.
Your client looks to you with pleading, searching eyes, not saying anything.
They might be looking to you for an answer. They might also just be looking to you for reassurance and lifting up. It doesn’t matter either way, I suggest the same response:
“This is a lot to think about. We are all here to support you. I remember you said XYZ when we talked about this a few weeks ago, but I also know things can change. How can we help you make your best decision right now?”
After that, you can prompt your client to ask about benefits, risks and options, always reinforcing that they have the ultimate decision-making authority. When I handle situations in this way, I’m sometimes totally surprised by what my client chooses as their best route. It might be different than what I would choose, or different than what I would expect based on our previous conversations. People can change their minds. In most cases, we’re working with adults. They own this decision for ALL. THE. REASONS.
Your client asks you directly what you would do (or what you think they should do).
Ugh, this is so hard! Because I have opinions, and I know you do too, doula. But going back to the idea that this isn’t our choice to make, here’s a phrase you can use:
“I would do exactly what you’re doing — gather all of the information about risks and benefits, and then make my best decision in the moment. You and [partner] have a lot of wisdom and good judgment. Do you need more information right now?”
That’s it. You can totally do this. I’ve found that once I got used to using these kinds of phrases, they now come second nature to me. I feel like I’ve lifted my client up, nurtured them in the truest sense of the word, fostered collaborative relationships, and my clients come out the other side feeling fully supported and happy with the doula experience. That’s good for all of us.
What are your thoughts? Have you faced these tough moments as a doula before? What wisdom can you share on how you handled it? Do you think it’s a problem when doulas speak for their clients — or not?