What does it take to become, and to be, a Doula?

Doulas often consider themselves unique among women because of their strong attraction to birth and caring for birthing women. At the start of one training workshop, each trainee shared what she thought made her unique.  Answers included such things as deep-sea diving, gourmet cooking, parachute jumping, or being the eldest of ten children.  Then the doula trainer said: “I love to be with women who are having babies.  That’s not unique here in this room, but in the world you’ll find it is.  What’s unique is that we’ve been given this bug to be with women at this exceptional transition in their lives.”

Doulas understand themselves to be ‘special women,’ who have a deep interest and ability to care for other women during childbirth.  This interest and ability is often characterized as ‘uniquely female’ but doulas readily acknowledge that not all women are interested in birth.   Among the many factors that bring women to doula training are a long-standing interest in birth and an orientation toward caring for others.

Many women described their reaction to finding out about doulas and doula training as something they had always been looking for but didn’t know existed.  They did not want or were unable to become a nurse, midwife or physician, but they still wanted to be around births.

It takes much less time and money to become a certified doula than it does to become a certified childbirth educator.  An unlicensed occupation, there are no formal requirements for calling oneself a doula.  However, the steps to certification involve finding an organizationally approved training workshop locally (usually available within a day’s drive of most metropolitan locations), paying for the course and materials, reading some books and spending time at a training.  Attending the required number of births and doing the paperwork to become certified takes a bit more time and effort.

Women come to doula training out of an ideological commitment to caring for other women during birth, often shaped by their own experiences. Doula trainers say women come because “some have had good birth experiences and want to share that with all women, and some have had bad experiences that they need to heal from.” Sometimes, women become emotional as they share their stories.  Trainers encourage personal reflection:  “Think through why you’re here. Those stories matter, there’s a lot to be done in understanding your own story of what brought you here.”

During training, doulas learn the definition and parameters of the doula role, the medical and emotional impact of doula-attended births and in particular, how doulas accomplish their job of providing ‘physical, emotional and informational support’ to the laboring woman while protecting the memory of her birth experience.

Doula care is presented as a return to the community-based, woman-centered care that existed prior to the shift from home to hospital births in the early part of the century.  In conveying this message, doula trainers emphasize collectively shared, community-centered support of women’s birthing experiences.  This focus asserts that birthing has been women’s work, that women intuitively know how to birth but our current culture has developed birth models that interfere with this intuitive knowledge and shared historical practice.  Doula trainers present an alternative model for how woman-centered support can reclaim a place within medicalized childbirth in Western cultures.

Trainees learn that their non-medical role is what distinguishes them from maternity care providers and this fills a gap within the current hospital provision of childbirth support.  Closing this gap takes two forms: first, the doula’s focus is specifically on the laboring woman’s emotional and physical comfort needs, rather than clinical issues.  Second, the doula provides continuous presence and personalized attention to one woman in contrast to the competing demands of the clinicians present, whether nurse, midwife or physician.

In addition to the focus on the non-medical aspects of their own role, doulas learn that pregnancy and childbirth are normal, non-pathological life events.  This notion is embedded in the midwifery model of care, described as a holistic approach; one that attends to the diverse aspects of pregnancy and birth: physical, emotional, spiritual, social, economic, cultural, and sexual. Trainees also learn the basics of childbirth physiology and other necessary information, but the emphasis is on birth as a natural physiological process occurring in healthy women, and the fewer medical interventions, the better the outcomes for both women and their babies.

Despite the emphasis on their non-medical role, doulas are nevertheless expected to be conversant with standard medical practices surrounding birth.  Trainees learn about pain medications used in labor, and the kinds of information they are expected to give their clients prenatally and during labor to help them make informed decisions.   Although critical of the unnecessary use of medical interventions, trainees are expected to be familiar with their indications.   Knowledge of anatomy and physiology of childbirth is encouraged in order to understand how to help labor progress in situations where the baby is not in an optimal position.

Doula trainers present the view that labor support should include unconditional emotional acceptance of women and their choices, practical physical assistance and as much information as women need to make decisions that are best for them.  Although trainers stress that birth is ‘not just another day’ in a woman’s life, and provide scientific rationale for continuous labor support, they also emphasize the importance of not judging women’s choices for their births or advocating one’s own beliefs on behalf of other women in medical settings.

Doulas learn that one of the most powerful ways they interact with their clients at births is by reframing what is happening from something that is negative or scary into something that highlights the normalcy of labor or the agency of the birthing woman.  Trainers communicate the value of reframing events in order for the woman to have a story to tell that places her decisions at the center.  Doulas are often present when the first telling of the birth story is announced to family members, especially when it occurs within minutes of the birth.  The injunction to ‘protect and nurture the birth memory’ is conveyed during training through a variety of means, including hands-on physical comfort measures.  But what the doula says is as significant as what the doula does in shaping the story of that birth for the woman, her partner and their families.

At the postpartum visit, trainees learn that the doula is there to see and admire the baby, and hear the woman’s story of the birth.  Trainers caution the doula to not assume that the woman will agree with the doula’s perspective of the birth.

Thus trainees learn that a large part of the doula’s impact on the woman’s memory of birth is accomplished through continuous presence, unconditional support, and reframing events, as they happen, so as to acknowledge and validate the woman’s effort.  In the event that the woman feels unhappy or disappointed about some aspect of the birth, the doula’s role is to validate her feelings about what happened, but reaffirm choices she made by reminding her of the factors affecting those choices. This reframing activity is a major part of doula training, designed to ensure a ‘positive birth memory’ for the woman, regardless of the doula’s opinion or experience of the birth.

Women who do not actively practice but intend someday to start or resume doula work still have a place in the doula world; they feel part of the community but are likely to have other family or life commitments.  No doula ever renounced the ideology, much like the phrase in midwifery, “once a midwife, always a midwife.”   As they continue doula work, many women move into allied childbirth fields that offer more professional status, better income and stable work.  Other doulas enroll in midwifery or nursing school to further their interest in technical aspects of maternity care as well as increase their earning potential.  Those who came to doula practice from another field, such as social work or counseling, continue to work in those domains but find their newfound experience working as a doula enhances their professional skills and empathy.

The typical practicing doula, then, is a woman who has been drawn by passion to provide care to other women during their births.  She has adopted a belief in the transformative and empowering effects of unmedicated, low intervention childbirth but also in the right and ability of women to make their own choices.  She strives to provide education and information to women that will give them an open mind to experience whatever lies in store for them at their births.  She networks intensively with others who share her beliefs and help her attain her goals.    Ideology, rather than professional status or economic reward, keeps her going, with the conviction that she is changing the world, and making a difference.