By Sharon Muza, BS, CD(DONA), BDT(DONA), LCCE, FACCE, CLE
Research indicates that between one-quarter to one-third of birthing people describe their labor and birth experience as traumatic. Lived experiences or a traumatic previous birth experience may all contribute to how a person feels during and after their birth. How a person is treated and whether they are respected and their voice heard before, during and after the process in addition to the clinical circumstances of the birth can all contribute to positive or negative feelings.
I very recently read a first-hand story shared on the Facebook social media platform from attorney Hermine Hayes-Klein, who is a consultant and advocate in cases concerning the treatment and rights of women during and around pregnancy and childbirth. Hermine supported a client in her local community who was hospitalized during a preterm birth concern. Hermine was present in the self-described role of “lawyer-doula” to serve her client. Hermine defined this term as a person who is present in the dual role of both attorney and doula, there to help their client prevent their human rights from being violated during childbirth and support the labor and birth process. You can read the entire account of Hermine’s experience here.
This term “lawyer-doula” is unfamiliar and new to me. I am not naive in recognizing that many birthing people are on the receiving end of disrespectful, hurtful care, where their voices and wishes are not heard or respected. I also know that these experiences have life-long negative effects and impact parenting, future births, and their lives in a significant, detrimental way. I have personally witnessed this type of treatment while attending births with my doula clients. I just know, after working as a birth doula for 15 years, that the role of the doula does not overlap with the role and responsibilities of an attorney. This joint role concerns me as a certified doula who believes strongly in following the scope of practice and code of ethics of my certifying organization. I immediately thought of the many ways that a doula can help their clients to not be in the position of needing both an attorney and a doula to support them during their childbirth experience. Below you will find steps you as a doula can take prenatally, during labor and after birth to support your client and help reduce the potential of an experience involving obstetrical violence, disrespect or trauma.
- Create a positive relationship of trust with your client, where they feel safe and comfortable sharing their fears and prior experiences.
- Support your client in developing plans for many contingencies, and identifying what type of support might be most helpful under those circumstances.
- Encourage your client to choose a facility and providers who are known for giving respectful care and shared decision making. Assist your clients in making changes if desired. I recognize the ability to change providers and facilities is often a sign of privilege and may not be an option for everyone.
- Help your client to create a short and simple info sheet with important background information that can be shared with everyone involved in your client’s care. This can serve as a reference when necessary.
- Consider role-playing situations to offer your client a chance to practice responding and making their voice heard.
- Share that your client has the right to respectful care and that they have a voice in every step of the process.
- Encourage your client to meet with the hospital or clinic’s patient ombudsman or patient representative in advance to voice their concerns about potential treatment and share their needs. In my area, one of the hospitals has a special nurse who meets with patients in advance and creates a “purple sheet” for L&D patients who have special needs and concerns. This purple sheet goes into the patient’s chart and everyone is aware of it when the patient arrives for care.
During labor and birth
- Remind your client that you are prepared and ready to help them find and amplify their voice if necessary.
- Encourage them to connect and share their own “simple info sheet” and also point staff to their chart for specific instructions, like a “purple sheet” (see above) with everyone who will be caring for them.
- Unless it is an emergency, ask your client if they would like a few minutes to discuss anything or regroup in private before things proceed.
- Describe what you are seeing happen out loud to your client and the room.
- Model good doula behavior (stop talking during contractions, keep your voice calm and soothing, use your client’s name, and repeat your client’s requests for clarification, are just some examples.)
- Encourage your client to state what they want at the moment and if they are able to articulate it, why they want that specific request.
- Support your client in obtaining information about all their options and choices.
- When your client’s wishes or preferences are not being honored, repeat your client’s request politely but firmly to the room so that everyone is aware of what your client has said. “I hear *client name* asking that the vaginal exam and cervical check be stopped right now.”
- If your client is uncomfortable with a specific nurse, midwife or doctor, help them to request a different one.
- Again, (because it is important enough to say twice!) help your client to voice their need for a “break” in care while they regroup or collect themselves and prepare to self-advocate for what they want.
- Listen to your client share their birth story with you, in their own words. Do not insert or substitute your observations or experiences with their own.
- If they express dissatisfaction with any aspect of the experience, ask them what might help them, what they might like to do or what they need.
- Let them know that they have the option to inform the facility of their concerns and dissatisfaction and help them to establish communication (written or verbal) with the appropriate people.
- Make appropriate referrals to therapists, mental health counselors, clinicians and support groups that can support them during the processing and healing from their experiences.
- Help them to receive logistical support (lactation, meals, family and friend support etc.,) that allows them to recover from birth and the transition of parenting a newborn.
- Let them know that their experience matters and they had the right to receive respectful and appropriate care and that they have recourse if they feel that this was not met.
It would be foolish of me to believe that everyone who births does so under circumstances where their voice is heard and they are fully respected. I know that is not the case. I am working for respectful and evidence-based care on a local and national level through my advocacy work. But I worry about what happens when the lawyer-doula shows up and attempts to work effectively in both roles at the same time. We can be an activist for change outside the birth room, but during a birth, we are of no use if we find ourselves removed from the birth room due to behavior that is outside doula scope.
How do you help your clients to receive respectful and appropriate care? How are you working inside the birth room to help your clients while still staying inside the doula scope of practice? What would you add to the list I have created above?
Wow, this article is very interesting and this is something I never even have thought about. Yes, doula scope at all times and the doula-lawyer has to leave her lawyer hat aside, specially in the birthing room. We advocate whether we are a lawyer or not.
I love this post and the reflection it inspires.
Is the purple sheet the same as the short and simple info sheet? I would love to see an example of a purple sheet. I would also love to see more concrete ways families could take active steps in notifying their facility or other organizations when they feel it is warranted (Joint Commission? Who else?).
Hi Stacie! The purple sheet is created by the specialized nurse at the hospital and placed in the chart. The simple info sheet is created by my client, and they bring it to the hospital or birth location with them and give it to the staff. I will ask my colleague for a sample purple sheet. Sharon
This is interesting . I get all the points about why this family benefitted by having an attorney presesnt. However, the attorney was not Doula. Her role was different in so many ways. Her skill set too. I believe we need clarity around the understanding of Doula. We have sleep doulas, RMT doulas, etc, etc. The DONA definition of Doula means very specific things. We have a clear scope of practise and are bound by our code of practice. The danger is that, by having employees who are calling themselves Doula present at births, it could negatively affect the perception of Certified Birth Doulas which we have worked so hard to foster with medical professionals. Here in Ontario , Canada , we are introducing a designation of Registered Doula of Ontario with the intention of bringing together Doulas with diverse training and experience, who meet a professional standard and work within an agreed framework to provide high quality care.
I liked what you said about how a doula will help create a positive relationship of trust with their client, where they can feel safe and comfortable sharing their fears and prior experiences. I’m pregnant with my second child and I want to try a doula this time around and see what it’s like with their services. Thank you for the information about how they will support their client in developing plans for many contingencies.
From your article: “I just know, after working as a birth doula for 15 years, that the role of the doula does not overlap with the role and responsibilities of an attorney. This joint role concerns me as a certified doula who believes strongly in following the scope of practice and code of ethics of my certifying organization.”
Needless to say, a doula cannot perform the vast majority of tasks for which an attorney is trained and licensed. But there is indeed an area of overlap between what an attorney does, and what a doula is supposed to be able to do for her client. The overlap is in advocacy– speaking and holding a boundary for someone when they cannot speak for themselves, and they have asked you to do so on their behalf– and in the duty of loyalty. Doulas, like attorneys, should remember that their only obligation and loyalty is to the client, and that this takes precedence over being liked by hospital staff. My “lawyer hat” was helpful and effective for serving my client in the role of a doula, but you don’t need a lawyer hat to be a effective doula and advocate.
“Scope of practice” is a nonsense term, when applied to unlicensed professionals like doulas. A more accurate term would be “job description.” An ethical doula won’t give a damn whether advocating for her client’s needs “could negatively effect the perception of Certified Birth Doulas which we have worked so hard to foster with medical professionals.” The medical professionals who have a problem with doulas are the medical professionals who have a problem with women’s rights.