Doulas & Homebirth

Earlier this month I posted to the CfM Facebook page asking for opinions about doulas at homebirths. I am the editor of the Friends of Missouri Midwives newsletter and was seeking contributions for the winter issue with the theme of Doulas. I received some excellent feedback from the CfM page "likers" as well as from the FoMM membership. As an extended companion piece to the article that eventually went into the newsletter, we ran the full article on the Friends of Missouri Midwives blog. Since CfM fans were contributors, I felt it appropriate to share the full article on this blog as well! Thanks to all who contributed their stories and ideas. We appreciate each one!

Doulas and Homebirth

Compiled by Molly Remer

The decision to hire a doula is a personal one, regardless of in which setting you give birth. My first baby was born at a birth center with the presence of a midwife, a doctor, my doula, a friend, my mother, and my husband. In hindsight, I felt like it had been too many people and that the doula hadn’t really been needed. For my second birth, at home, it was extremely important to me to have as few people present as possible. My husband, my mom, and my son greeted the arrival of my second son. My midwife arrived five minutes before his birth—just in time to catch! My midwife for this birth was so amazing, that I didn’t feel the need for any other professional care. I still miss her! For my third birth also at home, this time a second trimester miscarriage with only my husband present, I really wished I had a doula there for emotional support and supportive physical care tasks (not medical support, but tea bringing and towel washing). And, finally, with my last baby, while I liked and respected my midwife I didn't have the same warm bond with her and really wanted to hire a doula, precisely because I was missing some of the emotional component I value so highly in midwifery care. It is really the little things that make doula care so special. In the included photo my doula (FoMM President, Summer!) puts warm socks on me after my baby’s January birth.

Despite my own range of personal experiences, when calling for contributions for this article, I still anticipated receiving a number of responses suggesting that doulas at homebirth are unnecessary, or redundant. After all, an emotional connection and secure trust is often the hallmark of what differentiates the midwifery model from the medical model. However, the responses I received were overwhelmingly in favor of hiring a doula for a homebirth.

Finding inner power instead of crumbling in pain

Jami writes:
As I eagerly awaited my homebirth, I never considered getting a doula. I had two midwives assisting me, so I figured that would be enough, wasn’t that the same thing anyway? When labor hit in the middle of the night I could hardly function, I was in so much pain. Everything I learned in childbirth class went right out the window, and the same thing happened for my husband when it came to trying to help me. One of my midwives didn’t show up for a few more hours, so I was alone struggling with my blinding pain that whole time. Once she did arrive, and started walking me through my contractions, it made a world of difference. My homebirth ended up turning into a hospital transfer due to decelerations in my baby’s heartbeat during every contraction, and a doula was called out to stay with us while our midwives couldn’t. I don’t know what I would have done without her… Having to transfer to the hospital was a very scary experience, and when my much hoped-for homebirth turned into a much dreaded c-section, my doula was there as a voice of reason as well as much-needed emotional support. Looking back on the whole turn of events, I’m so grateful she was there and I have a whole new outlook on the work of a doula. There’s no way I’ll go through labor without one again. I had to get an epidural for the c-section, and that turned out to be the most terrible, painful part of the whole experience – much worse than labor by a long shot. Ever since my experience, I’ve been encouraging all of my friends to hire a doula for their births, whether they choose to go to a hospital or not. If they want a sure shot at avoiding drugs, a doula is the way to go at a hospital. And it makes sense at a hospital, but why would a home birth mom consider a doula? There aren’t any drugs or negatively persuasive doctors or medical staff to avoid there, and isn’t that the biggest reason to have a doula? I thought so, anyway. But doulas offer much more than a voice of reason against pressuring medical personnel. They help you find your inner power when you could easily crumble under the pain of labor. They erase fear that can easily find its way into your mind if you’re laboring without support. And, speaking from personal experience, they change labor from “painful” to “empowering”, turning it into the beautiful, positive experience it should be – you’re bringing a baby into the world! Something so wonderful shouldn’t be tagged with such a negative word as “painful”, and doulas make that possible. Labor is labor, no matter what your location is when you’re experiencing it, and having a doula there during it makes a huge difference.

A lasting legacy

Mandy writes: Hanging on my fridge is a note that reads, call me if you need groceries, a hug or anything! My doula put that there after I gave birth at home. For most of my pregnancy, I thought I would not need a doula at my homebirth; afterall, I had a wonderful midwife and assistant. As my pregnancy became more and more uncomfortable, I thought having extra support at my homebirth would be wise. I wanted the full attention from my partner, and I knew I would need my midwives to be able to focus their energy on the progression of my labor and on how well both our baby I were working together. My doula helped to support us as a family caring for my partner, our other child, as well as the much needed emotional and physical support that I ended up needing. It takes a lot of compassion and wise intuition to find the balance to meet the needs of both my family and the midwives. She provided massage, position suggestions, hydrotherapy, encouragement and cleaned, cooked, fetched things that were needed and even made coffee for everyone. While the midwives and I were caught up in the whirlwind of a difficult labor, she stood in the back keeping the peace. Every time I look at the note on my fridge, I smile and think about how deeply grateful I am to have had her with us on our birth journey.

And, Fabiane shares: My doula was my angel, she helped me through it. My labor lasted 36 hours and she was there all the way. She didn’t sleep, and I felt bad for her, she held me when I was in pain and scared, she told me everything was going to be fine. Her support made all the difference. Her kind words when I had to be transferred to the hospital made me realize I was not a failure for doing that. Meredith B. you are my angel!!!

Comparing experiences

Several women wrote sharing their experiences with both hospital births and homebirths and of a doula’s special touch.

Becky wrote to share:

We had a doula for four of our births, and a midwife for the last three. We had a midwife and a doula for one of them. We had a doctor who did housecalls for two of the births. We had a hospital birth that made us decide that the rest needed to be home births. We didn't have a doula for that one. I honestly wonder how differently that birth would have been if we had had a doula. Because the housecall doctor was much like a midwife would have been (although a different gender than most midwives), having a doula wasn't as important as if it had been hospital. However, having a female there was a lot better than a male doctor, and she stayed with me for the hours and hours (and hours) that I was in labor before we called the doctor.

Sara writes:
I had the same doula at both my hospital birth and my homebirth and it was well worth it in both cases. At the homebirth she obviously didn't have to function as a warrior/advocate like she did at the hospital birth, but it was still wonderful to have her there in a supportive role. My husband was there to give support as well, but there is just a different kind of support that comes from another woman, especially one whom you know has experienced what you are going through at that moment. It also seemed at both births that she knew just what to say at the right moment when I was having trouble, whether it was how to take the edge off of the contractions, or helping things move along when my pushing was ineffective. Having a doula there for mental and physical support provided comfort and assurance, while allowing my husband to be "in the moment" with me while my midwife could focus on the particulars of the labor and delivery themselves. I wouldn't have had things any other way and I would highly recommend having a doula at any birth, home or hospital.

The benefits of a doula:

Angela shares:

The midwife team I had for my homebirth were trained doulas. I didn't know exactly what would be midwife roles and what would be them acting as doulas. In hindsight I think having a doula with the midwives may have been a little nicer since it was my first homebirth/natural birth and the midwife seemed to be having to do a little more "technical" stuff than I expected but it probably depends on lots of factors. Either way, I did fine and the baby came out! My husband was there too doing his best. I look at it as a learning curve so I hope to have more kids and have less and less worry and pain with each birth! (doula or not!)

A midwife’s perspective

Debbie offered the following perspective on doulas at homebirth: I think doulas are wonderful for women choosing hospital birth. The kind of care the laboring woman gets from the hospital staff can really be supplemented by a doula. In that situation, a doula is a great benefit to the mother. I have a lot of doula friends, and I do not mean to disrespect them in any way. They go places and do work that I cannot emotionally handle. I am a homebirth midwife. I have had a couple interviews where a woman has asked if she should have a doula at her home birth. If someone wants to hire me and a doula, I will not try to talk them out of it. But I see my work as being a doula plus a midwife. I bring an assistant to every birth. If it’s a VBAC, I bring another fully-trained midwife. I don’t know what I would be doing during the birth if there was a doula there, too. If I had to sit in the corner and my only work was to check heart tones and catch the baby, I would feel like an obstetrician! I don’t want to do birth that way! I love birth! I love helping the woman through her contractions as they build and build. I love rubbing her back, holding her up, giving her bites of food and sips of drink, helping her squat, and breathing with her. During a birth I get tired, sore muscles from squatting and bending, sweaty from the heat, humidity and heavy lifting. But I wouldn’t have it any other way. I love my work!

Susan also wrote with the opinion that a midwife fills the doula role well: My experience of three homebirths is that the midwives play the role of doula as well. It seems to me that often one midwife is more "doula" and the other more "doctor", if that makes sense. The two together make a great team, and I'm sure their roles vary from birth to birth. If, perchance, there were only one midwife attending a birth, I believe a doula would be a wonderful addition.

A father’s perspective

Ben wrote to share his family’s experiences with doulas: Our first birth was in the hospital and it was horrific. I had been raised in an environment friendly to home-birth, but when it was my first child, I over-rode my wife's wishes and we had a hospital birth. It's one of the few things in my life I truly regret.

Our second and subsequent births were at home. We used a doctor who made housecalls on our first two home-births, but we also asked some old family friends to help out. They were doulas. I didn't even know what a "doula" was at the time.

From a male perspective, a doula is a life-saver. There I am, the 'extraneous' member of the family (during birth, at least)--but one who is wracked with emotions for the safety of my wife and child. My wife leans on me for her emotional support--and I was just as much an emotional wreck as she was, with that "I'm hiding my insecurities in machismo" facade. The doulas were as much a comfort to me as they were to her. Kind words, a hug, a held hand, those life-saver words, "It's okay, this is normal," a gentle suggestion to step away for a few moments. And when the baby came, when the emotions flooded over us both and all we could do is kiss and cry and hug and hold our life's joy in our arms together, the doulas were there to settle the room, soften the lights, take away the trash and clutter and afterbirth and details and all that myriad of things that neither one of us could even think about. While the doctor or midwife (we had both depending on the birth) was there to do all the technicals, to check on the health, the doulas were there to comfort, to settle, to relax the chaos of our lives and let us truly experience the first moments with our most precious treasure.

Men think about the costs, the finances, the harsh realities of life. If I were to give an expectant father advice about the new baby: Pay for a good midwife, pay for a good doula, make sure your wife is comfortable with both of them and slather the baby's bottom and diaper with vaseline for a week after birth (meconium was a real shock till I learned that trick). :)

Doulas weigh in

Genevieve: My favorite place to doula is at homebirths. I give my clients a discount for having a homebirth because, as I always tell them, it is easier on everyone! It's easier for the mom, baby, dad, doula, and midwife!

Hillary: I am a doula who has attended homebirths. It's a different thing. I find myself arriving before the midwife. Providing support for long labors so the midwife can conserve her energy for the important work she might need to do during the actual birth and immediately after. I find myself doula-ing the birth team. Making tea, providing support to the dad, taking pics and of course, supporting the mom as she wishes. I had a doula at my last birth and I relied on her a lot for emotional support during pregnancy. I'm so glad she was there.

I also posted to the Citizens for Midwifery Facebook page asking for input on the doula’s role at homebirth. While the responses were more varied, many women were squarely in favor of doula support during homebirth.

Opinions from the larger birth community

Gillian: As long as the doula understands that homebirths often need the doula to "do" less and "be" more I think it can be a great help to the client and the midwives. I did go to one birth with a control-freak doula who couldn't stop trying to fix everything but I think that was an anomaly.
What I notice, as a midwife, is that most clients are already paying for their homebirth care out-of-pocket and the idea of paying for additional support seems like quite a stretch. I haven't had any clients choose doula care for their homebirths unless the doula was also a friend or family member working attending for free out of love. I think I give really good support as a midwife so I don't think that my clients are lacking but during some births, especially the long ones, I can really see the benefit of someone else who can support while the midwife takes a snooze!

Christine: I was a doula before I ever got pregnant, so I actually had two at my first birth (one I had hired and one I had apprenticed with). Two was overkill, but my husband really appreciated having them there, probably more than I did! My next two births were fairly precipitous, so no doulas (although I had arranged to have one for the second birth). I loved being a doula at homebirths, and suspect that they are as useful at home (or maybe more so?) as they are in hospital. A doula empties the birth pool or makes supper for everyone, starts a load of laundry and rocks the baby while mom showers; basically does what needs to be done, so that everyone else can concentrate on their specific jobs...

Fonda: My last two were at home. Having to shell out nearly $4k out of pocket each time, paying for doula on top of that would have been impossible. That said, being at home I didn't really need one.

Maria: I had a homebirth but no doula. My midwife had two assistants and they acted very much like doulas, doing things like laundry, breakfast, partner support, etc. I also had a very fast labour, and think a doula would have been excessive. I recommend doulas all the time to my preggo friends, although I don't see myself ever hiring one...

Laura: I think one difference between home and hospital is that generally you know more what you are getting in advance in terms of support in a homebirth situation--usually you have one or maybe two midwives in a practice whom you already know fairly well prenatally, and perhaps an assistant or apprentice who works with the midwife. So you have a pretty good idea before you go into labor how much support and what type of support your particular midwife/practice will provide. In a hospital setting, the L&D nurse is really the primary potential support person besides a spouse or family member--and that is somebody you don't know until going into the hospital and it's a wild card how supportive or unsupportive the L&D nurse will be of your wishes or how much that person can/will do in terms of emotional support or comfort measures. I think doulas are more critical/necessary for that reason in a hospital setting than in a homebirth setting.

That said, I think it also depends on the particulars of your own homebirth situation. I hired a doula for my last homebirth because I had a midwife who worked alone (no assistant or apprentice) and I wanted to make sure there was an extra pair of hands/extra person available in case of 1) a long labor where my midwife and husband needed a break, 2) a complication of any sort, 3) as a backup support person for my older child in case her babysitter wasn't available to come and be there with/for her (no family nearby who could be with her during the birth).

Katie: I planned a homebirth with my twins, and did not have a doula. I ended up with a (pretty terrible) hospital birth and I WISH I had a doula. I will have a doula if I ever birth again, no matter where I birth (but hopefully it will be HBAC!), and I recommend EVERY mother I know to have a doula, no matter where she births.

Natalie: My midwife had an assistant at my three homebirths. I felt no need for a doula, but if I had a solo midwife or was planning a hospital birth I would want one.

Raissa: I had the same doula for my first (surgical) and second (home birth) and wouldn't have wanted it any other way. At home she came several hours before the midwife and really gave peace of mind for me and took some of the pressure off my husband. Worth every penny! (I literally paid for her with my babysitting money.) And, since the midwife got stuck in traffic, she unpacked the birth kit and almost got to catch the baby!

Elizabeth: We had our baby at home with the help of two midwives and a doula. Our doula was amazing. She is still the person from our birth team that I talk to the most -- it has been 18 months since the birth of our child. Her care and concern for my family's welfare has been ongoing and consistent. I strongly encourage any pregnant woman, regardless of where they intend to give birth, to hire a doula or search for volunteer doulas if hiring one is not financially feasible. I can't imagine having a baby in a hospital without a doula.

Kasey: I don't remember if the doula showed up during my labor or after to help my midwife, but my placenta wouldn't come out and I had to have a catheter put in, and since my husband was caring for the baby, the doula filled in (I'm petrified of needles and the like) and I have to say, I was very grateful she was there. If my husband couldn't have been there for whatever reason, I would definitely want a doula present, no doubt about that.

I really appreciate all the people who lent their voices to this article. I very much valued the specific and customized postpartum care my doula provided to me after my last homebirth and I’ve concluded that a doula has the potential to offer something unique and precious to families, in whatever setting the birth takes place. I also agree with Elizabeth’s remark above, that it does seem like the doula is the most likely member of the birth team to remain in contact with the family in the future. Perhaps it is because, even given the friendliness of the midwifery model, there is less of a "power differential" between mother and doula.

As we prepare to greet a new year, I propose this toast: Here’s to beautiful, empowering, healthy, fulfilling births for all women, in all settings, with the birth companions of their heart’s desire.