Earlier this year, at a prenatal appointment with a client, I was presented with a piece of paper that her care provider had given her, titled “Doula Agreement.” She was told that if she were to have a doula attend her birth, her doula would need to agree to the terms of the “Doula Agreement” and sign the paper acknowledging adherence to their guidelines.
My alarm bells went off immediately, but I took a breath, then the paper, and read.
The document insists that the hospital desires to “have a good working relationship with doulas;” highlights three distinct roles of a doula – physical / emotional support, comfort measures, and specialization in non-medical sills; and concludes with the sentence, “If the practice guidelines are not followed, the doula may be asked to leave the Labor and Delivery unit.”
The document made me furious. Its careful language, disguised as an act of chivalry protecting the pregnant woman from the incompetent doula, is condescending and patronizing to both the pregnant woman and to the doula.
Let me break it down.
1. The institution claims that they wish to have “a good working relationship with doulas.”
Here are some reasons I view this statement as mere rhetoric; nothing more:
A good working relationship demands mutual respect. Mutual respect would not allow for condescending “agreements” whereby one party holds the authority and the other is expected to simply be compliant.
In addition, mutual respect must be actively played out in a working environment. In this situation, that means at a birth. I can tell you that in my experience it is rare that I am given a working-level respect. I can also tell you that my experience of this dynamic is not isolated. Doulas are routinely treated quite contrary – ignored at best, treated adversarially, at worst.
When a prominent role of a doula is to ensure that the birthing atmosphere is peaceful, the projection of irritation or aloofness from hospital staff adds to the range of where a doula must spread her energy.
2. Spelling out the role of a doula.
Spelling out a doula’s role is insulting. It offends the mother’s intelligence. If a woman has taken the monetary and time investment to hire a doula, she understands the capacity under which the doula operates.
Equally, it offends the doula. A person working as a doula is well-versed on what defines her scope of practice. Spelling out a doula’s role in this way is the equivalent of a doula cooperative drawing up a Hospital Staff Agreement that quotes from the Hippocratic Oath.
What lies at the root of a document like this is the threat posed by the doula’s client-advocate role.
The document points out that a doula does not “make decisions for the mother.” The need to include this reveals a twisted understanding of the advocacy role. Never would speaking for or deciding for a client be part of a doula’s agenda. A doula’s advocacy role would actually preclude her from doing so.
One of a doula’s highest goals is for the mother to feel an immense sense of ownership and power through her birthing experience. Acting as a woman’s voice, would rob a woman of the authority and dignity that comes from speaking for herself. As an advocate, the doula spends a significant amount of time with a woman, prenatally, understanding her birthing goals and desires, and then acts to support a woman during her labor so that she (the woman) might achieve those goals.
The “roles” go on to point out that the healthcare provider is responsible to “focus on the safe delivery of the baby, assess and diagnose medical conditions and offer medical options, [and] inform and educate a woman about the care she is receiving.”
While it is certainly true that doulas do not perform medical or clinical tasks, doulas most obviously do have a huge investment in the safe delivery of the baby. Oftentimes the safe delivery of the baby includes things that doulas are experts in – things like a belief in and understanding of the normal process of birth, which allow her to offer comfort measures and position changes that encourage a calm mother and that can increase the likelihood for a smooth and uncomplicated labor.
And while doulas may not be able to suggest all medical options, let’s be real here about actually offering medical options.
A doula’s advocacy role in this dimension is pretty paramount, because almost no care provider actually provides true informed consent, which would include presenting all options and choices to the mother. A doula’s role is not offering medical options, but rather working with the mother in uncovering what her choices really are.
3. Concluding the “agreement” with the threat of being dismissed from the birthing unit.
Obviously, any “agreement” that ends with the threat of removal, does not promote a “good working relationship.” It does, however, succeed in a number of contrary things:
First it lays the foundational message, “You, Doula, are on our turf,” and it succeeds in promoting an adversarial environment at the birth.
Second, it reveals the hospital’s intent most clearly. It establishes the Institution as the authority, while diminishing the value of a doula.
“The doula is working for the mother. She is not an employee of the hospital or physician.”
This statement most succinctly points out the most glaring distinction between a hospital care provider and her doula: that is, the doula, alone, works for the mother. Unlike hospital staff, she does not report to an overarching institution and their administrators, or to an overseeing physician. Nor is she bound by policy, procedure or liability insurance stipulations.
When care providers are constrained to treating women as patients, their vision is skewed by by a plethora of factors that do not allow them to provide truly objective or woman-centered care.
Maybe a good follow-up article would be the flip-side of this document: A “Hospital Staff Agreement.” What items would you include in such a document?