Birth doulas are concerned about hospitals requiring signed agreements in order for them to practice their livelihood on the facility’s grounds. Some agreements outline scope of practice behaviors and even have vaccination requirements. My concern is that these agreements are seen by hospital leaders as an easy solution, without realizing that agreements without prior negotiation lead to greater conflict and tension, thus worsening the situation for their staff rather than alleviating it. They seek to save institutional energy and time, sidestepping the processes of defining the problem well or evaluating other possible solutions.
It’s also possible hospital leaders do not understand the doula’s role. A few months ago a very experienced labor and delivery nurse asked me about a doula who “just sat on the couch” most of the birth, only “getting up to help them change positions or go to the bathroom”. Her perspective was that the doula’s role was to tell the mother what to do to make her labor more efficient. This also represents a clash in values. In the hospital system, members have been socialized to believe that their primary value is in doing something. Our emphasis is on presence, a state of being that helps to create a safe space where oxytocin can flourish, the laboring person’s body can open up and use it’s own wisdom to get the baby born.
As someone who does frequent workshops and trainings for labor and delivery nurses, I can say that nurses gain their knowledge about birth from different sources; and often they do not know what doulas know. Nurses reading this blog very likely do, but they may not be the people in charge of solving the ‘doula problem’. Doulas read different research literature and have different conclusions. It is risky for doulas to assume that others understand our role or why we place value on physiologic birth. When people don’t understand the doula’s approach to enhancing labor, they misunderstand our actions and motives as well.
To me, the agreements and many doula communities’ reaction to them, are representative of a clash in values, misunderstandings about each person’s role, and short sightedness about the long term relationships that need to exist between birth doulas and hospital staff and administrators. Part of my reasoning comes from the hospitals and doula communities who have effectively worked through their conflicts and found solutions that work. Each group took the time to appreciate the other’s contributions, and develop a long term perspective that included a multifaceted communication network. In my next post, I’ll outline their achievements and share strategies to help get to that point in your own community.
If an agreement is being proffered by your hospital, this means that you have a sparkling opportunity to engage with administrators to resolve conflicts and outline your working relationship. This is a critical time to define your relationship with one another as it has the potential to influence all future interactions. In a way congratulations are in order – the doulas in your area are being seen as a big enough force that they can no longer be ignored. You’ve got their attention and can use it to create positive change in the system that benefits you, your clients, as well as the hospital. The hospital staff just doesn’t know it yet!
Let’s focus on some key questions that we need to ask:
First, has the problem been defined well? Agreements are seen as a solution to a problem that people belonging to the hospital are having. Usually it seems the doulas in the area are often in the dark about what the problem actually is. From what I’ve learned about people and medical systems, a solution can be latched on to without ever really defining the problem well. “I read on the internet that Hospital X was having a doula problem so they developed an agreement. We could do that too.” Having latched on to a solution, the group then moves forward without fully defining the problem first.
Problems that agreements may be seen as solving:
- Doulas who are using clinical skills while in the hospital.
- Doulas misinforming the person in labor about their progress.
- Doulas who are not being collaborative in their labor support strategies with nurses.
- Doulas who ignore nurse’s experience or expertise in support skills.
- Doulas who criticize a medical careprovider’s approaches.
- Doulas who give medical information that the hospital feels should come from their representative.
- Doulas who are blamed for their client’s strategies to delay or avoid interventions.
- New doulas who need mentoring, and the nurse doesn’t feel that is their role (the agreement serves a gatekeeping function, keeping newbies away).
Besides the first one, the rest of these problems are relational. In other words, they aren’t easy to define and will depend on the personalities and communication skills of the people involved. That is what makes the agreements so problematic – they really can’t define appropriate behaviors in an accurate way. For example, if an agreement states, “The doula will not openly criticize the medical care being offered to a patient”, what does that mean? What is considered “criticism” and “open”? Is asking about BRAND seen as criticism? Is bringing up alternatives critical? Is reminding a mother about her pre-labor priorities critical? How do doulas know? How do nurses know?
Second, are the perspectives of multiple stakeholders (nurses, physicians (all kinds including anesthesiologists), midwives, administrators, mothers, fathers, babies, laboring patients, family members, lactation professionals, doulas, social workers, etc) being taken into account? Having defined the presenting problem, who else is affected by it? What are their considerations that need to be taken into account? Have they been asked or consulted?
Third, what are all of the possible solutions to the problem? Are there other issues that have come up during this exploration period? What are the short and long term gains of each solution? What if instead of forcing all doulas to sign an agreement, we had twice yearly orientations for new doulas? What if the hospital sponsored events that covered the allowed safe discussion of most annoying behaviors of doulas in nurse’s eyes, and vice versa? What if nurses were free to ask questions about why doulas do things a particular way, without negative repercussions? What if doulas could seek to understand the nurse’s perspective without animosity?
In this way, hospital-doula agreements can be shortsighted. We don’t know what the goals of the hospital or the doula community are or whether they overlap.
Agreements that are created without communication between the negotiating parties will create tension and conflict. An agreement works best when it has been negotiated after a effective communication and conflict resolution process has been established. The agreement is the outcome of a negotiation. When it is handed down with authority as a “power over” move, it is doomed to create tension, defensiveness, and an anxious and tense work environment.
 Supporting Healthy And Normal Physiologic Childbirth: A Concensus Statement by ACNM, MANA, and NACPM (pdf file)
 Acronym for Benefits, Risks, Alternatives, do Nothing, Decision (after establishing that this is not an emergency)
For a doula’s insights on being handed an agreement, read: https://birthanarchy.com/hospital-doula-agreement/