Doulas and Midwives: Not the same thing

My article “Bad news about giving birth at Reston Hospital” has gotten a couple comments which, when combined with other emails from friends who ought to know better, made me want to write a bit more on this subject. I think I am going to stop using the words “doulas” and “midwives” in the same sentence, starting now. Too many people think that the two are related or similar. They’re not. When you’re a hundred miles away, two things that are miles apart can look pretty close together.

People who think that “normal” birth is in a hospital and nominally overseen by an obstetrician seem to view anything non-medical as more-or-less the same thing. That’s the hundred-miles-away thing. The reasoning seems to go: “A doula’s not a doctor. A midwife’s not a doctor. They must be similar.” They’re not. If you’re going to have a birth, I strongly recommend a midwife as your primary caregiver. Having a doula around might be nice, too. They have a special role to play, but they’re not the same.

I pointed out that Reston Hospital has a policy against doulas. Doulas, while many are trained and certified to significant standards, are not recognized by medical boards the way doctors and registered nurses are. Thus, for a hospital to have a policy against (in their view) unqualified attendants is (again in their view) justified. On the other hand, no hospital is likely to have a policy against certified nurse midwives, because that’s like having a policy against registered nurses. It doesn’t make sense. So what I said about Reston Hospital is that they ban doulas. Coincidentally, but unrelated, they have no currently practicing midwives there. There aren’t many midwives in the area as it is, and the ones that are around don’t work at Reston. So “ray” who agreed “with the hospital’s decision not to allow doula’s and mid wives,” doesn’t get that difference. The hospital doesn’t ban midwives. The midwives choose to work elsewhere.

Folks who lump midwives in with other caregivers simply because neither is an obstetrician have no earthly idea what they’re talking about. Consider the dentist’s office. You don’t lump dentists in with dental hygienists. Sure, you see both at the dentist’s office, but one has been to medical school and is the equivalent of an MD. The other has been to significant training, but not at the same level, rigor, and depth. Certified Nurse Midwives are RNs and then some. (In Virginia, “direct entry midwives” are also now legal, but there are very few of them. In this article, I’m only talking about CNMs) They serve as primary care providers in some situations and they even have limited abilities to write prescriptions. Doulas on the the other hand, are trained in helping women cope with labor, understand their body’s signals, and get through labor well. They do a lot more, but I have less experience with them so I don’t want to get too far afield. Anyways, one is a registered nurse who went on and got further medical training in childbirth. The other is a lay person trained in helping with emotional and physical aspects of labor, but not medical issues.

So the notion that midwives “sometimes ” are more of a distraction than help (many a times they argue with the doctors/nurses, right or wrong”, and create a chaotic environment” is absurd. Midwives are the nurses. A well-trained doula does anything but create chaos, since chaos and stress work against labor—something doulas understand well.

Consider the other comment on my blog, from a woman who had significant problems with her birth and would not want to deliver at home. No argument here. Midwives are not the same thing as home birth. Again, people tend to lump all the non-obstetrician stuff together. Midwives, home births, it’s all the same. It’s not. Could a midwife have led that high-risk birth? I think most midwives would say “that’s high risk. I’m going to refer you to our obstetrician.” Rightly so, and well done. In fact, in Virginia, all CNMs are required to be affiliated with an obstetrician, who presumably collaborates on their work and handles the high-risk pregnancies. The midwife can attend and assist like any nurse can, and arguably better than an RN because of her/his additional medical training. Midwives only lead the low-risk, normal births, which, by the way, is the vast majority of women. They’re trained to recognize signs of high-risk circumstances and call in obstetricians at the right time. This is real, medical nursing.

Then there’s the issue of having a doula when you’re eclamptic and hemorrhaging and all that. Given that a doula is not a medical practitioner and isn’t expected to address the eclampsia or hemorrhaging, you have to decide whether she can be of service to you in one of the ways she is trained to help. Can she help you relax and get through it with greater confidence and comfort? If so, get yourself a doula. If having that person around will not actually help you, then a doula is not for you. Does a doula have a place in a high-risk, high-intervention birth? Absolutely, if everyone is on-board with that decision. If the mother will benefit and the medical staff are amenable, a doula can be a real asset.

I never argued against hospitals. I argue against the artificial norm that hospitals are establishing. Having a baby at a hospital is safe and its a great place to be. The interventions, however, (pitocin, epidurals, caesarians) should not be seen as normal. They have their uses, but obstetricians and hospitals are reaching for them much too often, to the point that women don’t realize that childbirth can happen perfectly well without them.