There has been much conversation in the doula community about contract language which outlines a specific number of hours of labor support included in the base fee and how to address support beyond that period of time. In the most recent International Doula magazine, DONA International founder Penny Simkin reflected on the “12 hour clause” and, with assistance from her colleague Katie Rohs, conducted an online survey of doulas on this topic. — Adrianne Gordon, MBA, CD(DONA), Blog Manager
The 12-hour clause regarding use of backup doulas and/or ‘overtime’ fees
By Penny Simkin and Katie Rohs
I was asked to reflect on this topic, which has become a sensitive issue in the doula community. In thinking about how to address this, I thought a survey of doulas’ practices regarding this topic might be enlightening. I asked Katie Rohs, my colleague, an experienced birth doula and a social media- and computer-savvy person, to join me in preparing this column. She designed the survey and tabulated the data, and also offered her perspective as a birth doula. The tables below present some data from this informal survey, which was returned by almost 1,700 doulas, 314 of whom include language in their contracts describing some version of the “12 hour clause.” These 314 responses are summarized in this column, along with our responses.
We want to remind the reader that this is not a scientific analysis of doula practices, merely an online poll, with data and perspectives supplied by a large number of doulas. We think we have gained valuable information about doula practices that is worth sharing.
What is the 12-hour clause?
Our survey revealed that there is broad interpretation of this term, which basically refers to language describing the number of hours included in the basic package price and what happens if labor goes longer, in the form of additional fees, a shift to a backup doula, or end of service. On social media, some doulas expressed concern about the use of the term “12-hour clause” or “limit.” They do not see this language as stating a “limit” on the number of hours they will provide support; rather, this is the base number of hours that are included in their doula fee. If labors continue beyond this amount of time, hourly charges apply. In deference to that objection, we will use the term “overtime clause.”
|Does your doula contract have language regarding the number of hours of in-person labor support?|
|Yes||18.71%||314 entries (These are the entries used for the calculations below.)|
|What happens at the conclusion of the included hours of labor support, if you are still with your client? (n=314)|
|I leave.||1.6%||5 entries|
|I call back-up at no additional cost to the client.||23.64%||74 entries|
|I charge an hourly rate.||47.28%||148 entries|
|I offer the client the choice of me leaving or paying hourly.||1.92%||6 entries|
|I call a back-up and charge the client an hourly rate.||5.11%||17 entries|
|What is the point at which some change (backup, break, additional fees, etc.) occurs? (n=314)|
|12 hours||29.94%||94 entries|
|12-18 hours||24.84%||78 entries|
|18-24 hours||29.98%||91 entries|
|Are you a certified doula?|
|In the process||26.59%||447 entries|
|Who is your certifying body? (all respondents)|
|Birth Arts International||2.52%||23 entries|
|Birthing from Within||0.44%||4 entries|
|Childbirth International||6.92%||63 entries|
|Who is your certifying body? (those who include some language regarding hourly limits; n=168)|
|Birth Arts International||1.19%||2 entries|
|Birthing from Within||0.06%||1 entry|
|ProDoula||10.12 %||17 entries|
|Childbirth International||8.33%||14 entries|
As we can see in the first table, the vast majority of doulas who include language in their contracts about number of hours of labor support either 1) remain with their client and charge an additional fee; or 2) call in a backup, with or without charging an additional fee. As realists, we all know that doulas have limits, needs and other obligations that cannot be ignored, and they are not the same for all doulas. Furthermore, labors and laboring women also differ in the demands they present to the doula.
Limits make sense if this calling is to be sustained. Each doula’s limits need to be tailored to other demands – family, job, financial need, health, stamina. They also must take into account the clients’ needs and local fee structures for doula care.
The survey included these open-ended questions.
Why did you decide to have this language? How does it impact your work/life balance?
Altruism – putting the needs of another ahead of one’s own – is a common trait among doulas and may be essential to providing excellent labor support. Altruism may also be the element that contributes to rapid burnout and the high attrition rate of birth doulas. Half of the 314 doulas who include an overtime clause added this clause to their contract after they had a number of very long births, (some of which caused the doula to actually lose money), and recognized that a career as a birth doula wouldn’t be sustainable unless they made some changes.
Child care is often reported as a barrier to sustainable doula work. Some survey respondents stated that they have childcare costs when they are at births, and that a flat fee with unlimited hours of labor support not only reduces the hourly rate they receive, paying an hourly rate for child care brought their earnings down further. Some doulas also worried about health risks from exhaustion and stress from long labors without a relief doula. Some cited sacrifices made by family members and strains on family relationships due to resentment felt by those left to keep the household running smoothly (without pay) while the doula was at a long, unpredictable labor.
Once the added fees for long labors and for backup doula expenses were instituted, many doulas said they felt much better about the long hours and about calling in a back-up doula who is paid by the clients rather than the doula. One doula said, “I can see myself being a doula forever like this” (with overtime pay and use of a backup doula). Another said, “It makes this a sustainable career. To be able to say and know I will not be gone more than 18 hours is a game changer and makes me a much better wife, mom and doula.”
How do the clients receive this? What questions do they ask about it?
Although the doulas who add these hourly fees after a specific number of hours were in the minority of respondents to our survey, they stated their cases clearly and succinctly. Few reported any downside, though some described feeling conflicted. As one doula said, “I believe an hourly model really does not serve women at all and is unfair to the mom. But I also believe each doula should do what they need to do, and as long as a woman is willing to agree, then it is up to them.” We think her statement summarizes the dilemma very well.
There are few topics that generate greater debate among doulas than having overtime fees and changes of doulas. There are passionate voices on both sides of the debate, and there isn’t likely to be a consensus at any time soon. One thing is clear, however – the expectant families need to fully understand the way the doula has set up her contract, the included number of hours of support and changes in care or fees (i.e., backup doula, additional hourly fees, etc.) that may take place. These conditions should be clearly understood and documented before signing the contract.
Our concern is that, like many other aspects of labor, it is not possible for clients to anticipate how they might feel in the midst of a long, exhausting labor if her doula leaves or puts off being with her client in early labor, just as women cannot anticipate the pain of labor or the exhaustion, or the difficulty in thinking through complex medical decisions while in the throes of labor. In advance, of course, it is rational to pay overtime and/or have a backup doula. It would be sensible for clients to calculate the cost of labor support for varying lengths of labor. For example, a doula might have a package for $1,000 that includes 12 hours of in-person labor support and additional hours charged at $50/hour. The client may then think, “If I need my doula for 16 hours, my cost is $1,200; $1,600 for 24 hours.” In fact, a prospective doula should encourage this kind of thinking as part of their decision to sign the contract.
Let’s inspect this kind of service from the client’s perspective. The idea of switching doulas in the middle of a challenging labor may be more distressing for the client than it seemed when they previously agreed to the overtime policy. Their emotional needs are difficult or impossible to imagine ahead of time when their rational, sensible side is guiding their judgment. Having the doula leave during a challenging time in labor sometimes leaves the client (and partner) feeling abandoned and less able to adapt immediately to the brand new backup doula. They may feel resentful or angry, especially if the labor ends in a disappointing or traumatic outcome.
Is there a solution that considers both the doula’s and the client’s needs?
Long, exhausting, complicated labors are extremely challenging for all involved. Such labors require flexibility, with as much consideration as possible for the client’s and the doula’s needs. (It is worth noting that doulas are often greatly appreciated when they accompany their clients through such labors, and doulas often perceive those as some of their most rewarding and soul-enriching labor support experiences, despite the sacrifice they made.)
We think that doulas who need an overtime clause should plan to be flexible under some circumstances, such as when the doula still has plenty of energy and some free time after the birth to recuperate, when the birth appears to be only an hour away, when there is a close connection between doula and client, or when there is a needy client the doula believes would benefit from the doula’s continuous presence. An overtime clause calling for an extra fee or a backup doula may be seen as a safety net that the doula chooses to ignore under some circumstances. Yet, having it in place when she needs it protects both client and doula from any misunderstanding. When transferring care to another doula, do it gradually to help the client adapt to the new doula.
In conclusion, we have used a survey of doulas’ policies and opinions about the 12-hour clause, or overtime policy, as the basis of a discussion on the pros and cons of a policy of charging additional hourly fees and/or calling in a backup doula in long labors. We discussed ways to meet the needs of clients and doulas in the unpredictable circumstances of childbirth.
We hope this discussion promotes introspection and reflection among you, our wonderful doulas.
In the Doula Spirit,
Penny and Katie
Thank you for this thoughtful and respectful discussion. I would like to see more research on the long term health effects this job has impacted as well.
Gracias Penny Simkin and Katie for this extensive work and reflections about our work, as doulas and our clients. This truly is a topic among of us here in Oregon with Doulas Latinas. Despite of much discussion over the social media, it is important such kind of more structured survey. But, if possible, in the near future, something that can also be seen as scientific based process to support such arguments and conclusions would be wonderful!
What an insightful survey! Thank you, Penny Simkin & Katie Rohs. I have a couple of considerations I would add to the findings and discussion: (1) Some parents can feel guilty about keeping their doulas for extended amounts of time (24+ hours), especially if they are aware of the doula having young children left at home. Having an overtime policy may reduce a laboring couple’s feelings of guilt and keep them in a more effective emotional state for productive labor, and it also may motivate couples to find strength to labor without the doula’s in-person assistance for a more appropriate amount of time in early labor, reserving the doula’s energy for the time when it may be more needed, later on. (2) The energy of a doula may decline after a certain amount of time; with another doula stepping in or with compensation as a motivating factor, the laboring couple may be more likely to receive better support towards the end of their long labor.
This survey is very thought provoking. Can you provide example of the overtime or 12 hour clause used by some doulas?
I am able to be a doula because my children are adults and l am low income by choice. For some hourly fine for me if would defeat the purpose and.creativigy of what l.do.
I work in a partnership with two other doulas and we charge a flat rate and then hourly after 24 hours. We interview together, we do our prenatal visits and our childbirth classes together, and there is complete continuity of care. If one partner joins another partner at the 12+ hour mark, there is a smooth transition and our clients report feeling fully supported by all of us.
I have always worked with a partner doula – the family meets both of us throughout the pregnancy (we alternate visits after the consult) and the family understands that we spell each other as needed during the labor, birth and 5 postpartum visits. We do NOT have an overtime fee and have strong feelings against it. Money seems to work itself out – trust! Some families give a bonus, some families give a great deal of thanks.