Thursday, July 01, 2010

A physician speaks about doulas and birth plans

This comment just came in from Kingsdale Gynecologic Associates: Doula Ban and Birth Plan.
So I am actually a physician. Doula's may be beneficial in some situations, but you all must remember that the role of a physician is to provide good medical knowledge and advice based on evidence. Where Doula's may be thought of as positive most have zero training and often times may give inaccurate medical advice which is out of their scope of practice. If people want Doula's there should be a government agency licensing those individuals. As you wouldn't want just any person playing your doctor the same gaves for those helping. If they obstruct what we are trying to do they are not beneficial and can ultimately hurt you. Further, they do not have any medical liability. If you want a Doula they should accept medical liability for the 18 years that OB gyns do. In regards to birth plans. They are all nonsense. When it comes to the delivery room most if not all mean nothing. Your in pain you said I don't want drugs you change your mind you get drugs. Happens everywhere all the time. Look the most important thing is not extra personnel in the delivery room. The important thing is a safe and healthy delivery for both the infant and mother. Any mother or father for that matter that thinks anything else is more important should not have children till they get their priorities straight.
Let's discuss this comment from multiple angles--research evidence for/against doulas, personal experience as a doula/birthing woman/nurse/physician/midwife, role and usefulness of birth plans, desirability of licensing and malpractice insurance for doulas, etc.

Here are a few links to get the discussion started:
Have at it.

30 comments:

  1. I just hate the statement in regard to birth plans- "In regards to birth plans. They are all nonsense. When it comes to the delivery room most if not all mean nothing."

    Life is unpredictable, but still we plan how we want our days to go. We plan to go to work walking, driving, etc. Maybe we will get into an accident and not make it, but no one blames us for expecting to make it to work. "why did you plan to go to work and then to the grocery store?! That's just asking for something bad to happen! You'll end up in the hospital for sure!"

    Funny no one says that, but as soon as you write a birth "plan", nurses scoff and you'll "end up with a c-section for sure!" We know that most women can and will, under the right circumstances, have an uncomplicated labor and will end up with a healthy baby, so why shouldn't they have expectations for that?

    I agree that it's not a good idea to cut and paste a birth plan on the internet and not do any research, however I think that most women who care to write a birth plan are putting a little more work into it than that.

    And maybe Mr. Physician can learn how to spell if he wants to defend his non-evidence based practices.

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  2. To me, even if a birth plan isn't followed at all, the mom should write one- it requires her to research and think about decisions that may come up. But she also needs to be flexible. If she does all the research without a plan, I think that's just as good. I do think some women can hold too tight to their plans and forget to do research about choices to make if things (heaven forbid) don't go according to plan.

    As for the doula comments- ridiculous (with bad grammar/spelling besides;)). If they can have 6 hospital staff in there for a labor, they can handle one doula. Let her replace the anesthesiologist.

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  3. Glad I'm not the only one twitching at the atrocious grammar and spelling. I'm kind of jaded to this attitude now...yes yes, doulas are stupid and birth plans suck, we get it, but MY GOD, man, you went to school for HOW many years and you still don't know the difference between your and you're, or how to use a damn apostrophe??

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  4. Somehow I struggle to believe that someone who can't spell could make it into med school. Thus, I have a hard time believing that this guy is actually a doctor. Rather I think it's someone who has a beef and is pretending to be a doctor to bolster his position. Which is a stupid position to begin with.

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  5. 1. The grammar is making my toenails curl. Learn how to use an apostrophe properly, doc!
    2. If a healthy delivery for mother and baby were really the number one priority in the delivery room, our mortality rates would look a heck of a lot different. I'm not going to trust an OB who throws the dead baby card into my face.
    3. While there may be some uncertified doulas, there are actually several organizations that regulate the profession.
    4. Overall, this just sounds like someone who's pissed that women are demanding better care from him. Care that makes them the active participant in their labor rather than someone who is lead by their OB like a sheep to the slaughter of the interventionist birth and/or c-section.

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  7. I wanted to rewrite my comment to make better sense. I think that quote is appalling, but I kind of doubt a physician wrote it. Most times they try to hide their biases a little more than that or at least throw in some numbers or facts, and the person's writing comes across as distinctly uneducated. I find it interesting though that we jump to the conclusion that this commenter is a man (I couldn't see any identifiers for either sex, though maybe I skimmed too quickly) because Ob/gyn is becoming an overwhelmingly female physician specialty (obviously there are still a lot of old guy OBs around, but are they reading blogs? Just a thought)

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  8. The grammar is atrocious - agreed! I doubt it was an MD writing what was written in the post. Way too many grammatical errors.

    I'm all for brief birth plans/preferences, and good labor support (family, friends, doulas).

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  9. hey, like I said before, I'd rather a physician be upfront about what and unknowledgeable pushy jer... I mean person he is from the get go. that way everyone knows right where he stands and can avoid him like the plague! ;)

    Physicians are a doubled edged sword. They have a lot of experience in medical procedures (well ok those that have been in the game long enough that is) and They often have the benefit of experience of what normally happens in the delivery room on their side. They also know what most women want (or the know what most women are bullied into, depending on how you like it).

    the problem (and I can't stress this enough) ISN'T the opinionated pushy know it all physician, it's the clients that hire him/her repeatedly giving that person the idea that they are indeed correct in their assumptions of how medicine should be practiced.

    unless and until people start realized THEY are the ones in charge of their bodies and they need to learn a thing or two about how their body's work nothing will change no matter how many doulas stand at the door with picket signs.

    I don't mean to seem snarky... it's just this topic is brought up over and over and over again and generally it's just preaching to the choir. What needs to do be done is educate the masses and that is no easy task! but... revolutions aren't done in a day. however every time a woman makes an educated choice, it knocks down know-it-all arrogant physicians down another peg into their rightful position of. Every educated decision is not just an "empowering experience" it's a vote for the rights of people everywhere - especially pregnant women and their babies.

    we are owed medical care from people who treat us like human beings who have the right to make choices, EVEN when it's against what the physician would do. Even the school board works this way for goodness sakes! But.. for whatever reason when it comes to health in general is seems the masses of our culture take a big "eh whatever, let the docs handle it" attitude. and lookie where that gets us? *sigh* people need ot get off their duff, stop watching TV and eating junk food and think for themselves!

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  10. p.s. I forgot to add that I'm a doula who worked at a hospital as an on-staff doula (who was trained by the hospital outside of my doula training) AND as a homebirth doula.

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  11. Aside from the many MANY things I could say about this statement, I have to ask: Is this really truly from a KGA physician? The verbiage in the statement sounds not only un-educated, but poorly written.

    That said, the words given hardly come as a surprise in this day and age, where the typical OB doesn't want to be bothered or put out. Ridiculous.

    To repeat what a previous poster commented on a previous post, I'd bring my doula and say she was my sister. Hey, maybe I have a highly educated sister who's well experienced in assisting women through childbirth - you know, someone who actually cares.

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  12. p.s. if I lived anywhere near this practice I would take this statment right here, the e-mail address from which it came, and publish them BOTH in the local paper.

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  13. I'm uncomfortable with calling a birth plan "nonsense" which is saying that a patient thinking through her preferences and values and expressing them is nonsense. From a nursing perspective, the goal is to provide care that is relevant to the patient and his/her culture. The plan of care is always supposed to involve the patient and should reflect her values related to her health.
    I just don't think there's a place to speak in such a derogatory way about a patient's wishes.

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  14. Ok, I chafed at the grammar too, but lets address the substance of the complaint. Whether or not the poster is actually an MD, the points s/he made need to be refuted. I am a doula and I work for a doula agency that provides services for mothers with medical assistance. I see a unique side of doula service, having private (wealthier, more educated, likely white) clients, and moms on medical assistance (poor, more likely black or hispanic, often very young).

    1) "Doula's may be beneficial in some situations..."

    Yes, doulas are beneficial for any woman who needs one. "Doctor knows best" but frequently doesn't tell mom about what procedures are routine in the hospital, what procedures could happen, or even let moms know they have a choice about which procedure they'd prefer. Doulas remind moms to ask questions if they're confused, take the time to consider the options (prenatally and during non-emergency labor), and make an informed decision. That empowermennt of moms can make OBs and nurses uncomfortable. Instead of a nice, quiet, compliant patient, they get someone who needs to understand the risk/benefit before they consent.

    2) "...the role of a physician is to provide good medical knowledge and advice based on evidence."

    True. Too bad so much medicine practiced in labor and delivery is defensive, not evidence based, and poorly explained, if at all, to the laboring mom. And the poster makes I point I totally agree with! Its ADVICE based on MEDICAL KNOWLEDGE. It isn't the law, or rules from God. Moms have the right to informed consent, or informed refusal, of ALL procedures, just like all other non-pregnant patients have the right to refuse unwanted tests and procedures.

    3) "Where Doula's may be thought of as positive most have zero training and often times may give inaccurate medical advice which is out of their scope of practice."

    AMEN! Doulas do not give medical advice, they provide continuous physical and emotional support and ADVOCATE FOR THEIR CLIENTS. If this poster has seen doulas giving medical advice, that was improper and goes against the Standards of Practice and Code of Ethics of DONA International (one of the international certifying doula organizations).

    I do disagree that "most doulas have zero training." While its true that anyone can call themselves a doula, there is an extensive, years-long process of training that certified doulas go through. Perhaps this medical center would be better off to require only certified doulas, or trainees being mentored by a certified doula.

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  15. >>The grammar is atrocious - agreed! I doubt it was an MD writing what was written in the post. Way too many grammatical errors.>>

    LOL... I thought this was my (former) OB/GYN writing. She is well-spoken and graduated from a decent medical school but her grammar and spelling are atrocious nonetheless. I know. I still have e-mail from her, saved in my archive.

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  16. I have a difficult time taking this person seriously and believing that he or she is really a doctor. I think this is just some troll out for kicks.

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  17. This guy has some valid points from his position. I seriously doubt he'll ever be a Dr. Wonderful, but here are his two free clues and a chance:

    1. There's more to a safe and healthy birth than physically surviving it. The medical system has long neglected to support mothers' and babies' emotional and spiritual wholeness. Doulas can help fill this gap as part of the TEAM.

    2. Heisenberg, the physicist said that what you observe, you inevitably change. This has implications even for obstetrics, and you should work these out for yourself.

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  18. As a doula who has seen OBs who respect birth plans and have a partnership with their patients, I think that birth plans can have a useful place in births for moms who are educated and prepared for birth.

    If a mom fills out an online birth plan without understanding what choices she is marking, that is silly and pointless.

    Having a doula can be a HUGE help to mom and also the staff. I have had many nurses thank me for being there. I have many OBs in my area who recommend their patients get doulas, especially if they want NCB. They also recommend they take Hypnobabies classes.

    I love that at least 1/2 of my students and doula clients have been referred to me from the local care providers.

    If OBs are open to doulas and birth plans I think that womens births would be better.

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  19. Maybe, if a birth plan is overly verbose, full of out of date info, etc, like some of the ones at Navelgazing Midwife, I'd get how it could be unhelpful.

    But, we had a one-page, bullet-pointed, just-the-highlights birth plan. We even highlighted the big takeaway: PLEASE DO NOT OFFER PAIN MEDICATION. We made 10 copies so anyone who came in could pick one up.

    Guess what? No one offered me pain medication, even when I'm sure the noises I was making could have been heard anywhere in the L&D unit. And, in the end, I didn't need them. When I read this "doctor's" (in quotes because s/he is an anonymous commenter and offers no evidence that s/he is really a doctor) comment that "Your in pain you said I don't want drugs you change your mind you get drugs. Happens everywhere all the time," how many of those people were unsupported and badgered by (perhaps well-meaning) nurses until they doubted their abilities and gave in?

    Which, in my opinion, illustrates just how much doulas are needed!

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  20. This comment has been removed by the author.

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  21. What I wanted to say was too long, so I responded in a blog post.

    http://birthunplugged.blogspot.com/2010/07/role-of-doulas-and-birth-plans.html

    (the first time, part of the url was missing, so that's why I deleted it)

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  22. Egad. The grammar. I can't believe he is actually a doctor either. The grammar sucks, but it's also poorly articulated, poorly argued and full of flaws and lack of actual research. Yikes.

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  23. Agreed on the poor grammar and syntax. I refrained from addressing that in the original post because a) I think the language speaks for itself and b) last time I commented on someone's grammar, it raised a firestorm. Whether or not "anonymous" is really a physician, the arguments are still worth addressing (not in the sense that I think they're terribly compelling, just that they bring up so many misconceptions and assumptions).

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  24. I know that for me, the entire REASON I became a doula was because of the vast research on the importance of their role in labor and birth. Beyond the statistics (lower C-section rate, lower induction rates, less interventions, less request for pain meds) the best way to know how well Doulas are working out to ask women who have used them!

    I have heard a few horror stories of doulas (probably not certified, I am guessing) who have overstepped their bounds and tried to interfere or give medical advice. Any TRAINED and certified doula is well aware of her role, and will not cross these boundaries. It's possible that a doctor (setting aside the possibility that this particular post wasn't written by one) could have had such an experience with a doula. That is unfortunate.

    Rounding up and generalizaing an entire group of people (in this case doulas, but it could also be Christians, OBs, gay people, whatever) is pretty dangerous, and that is what his greatest argument flaw was to me, ESPECIALLY when research proves to be contrary to his quick assumptions.

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  25. I've been mulling over this post for a few days now.

    It is shocking the amount of patriarchalism doctors approach women with. Whatever a woman's choices concerning her birth, she should always be treated with respect.

    I'm thought a lot about birth plans as a childbirth educator and doula. I've come to the conclusion that in an ideal circumstance, you should not need a birth plan. Your midwife (or doctor) should have the same goals for your birth as you do. It should be automatic that a woman would want a peaceful, barely interrupted birth experience. In some cases a birth plan might be a series of personal choices (music? water? positions? location?) that a caregiver might right down to remember them. I am in the camp of Navelgazing midwife - if you want a home-like experience, you should have a baby at home. You'll be happier in the end.

    I was blessed to have a very nice hospital birth, where I didn't have to decline anything (true intermittent monitoring was standard, no heplock, episiotomy, etc.) and I wish those women who had hospital births could have that type of experience too.

    As for doulas.... I know the research. I am a doula. However (and I might get major flak for this), I don't think they should be a necessity the way that they are. I wish a woman's needs could be met between her compassionate birth team and her loving family and friends. I feel that doulas are a stop-gap measure to try to fill in the holes left by a terrible system of maternity care. Does that mean that I hate doulas or think they should be kicked out of hospitals? No. I just wish that maternity care in our country and our birth culture were such that women didn't them.

    Please don't crucify.

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  26. Meg,

    Regarding what you said about doulas:

    "
    As for doulas.... I know the research. I am a doula. However (and I might get major flak for this), I don't think they should be a necessity the way that they are. I wish a woman's needs could be met between her compassionate birth team and her loving family and friends. I feel that doulas are a stop-gap measure to try to fill in the holes left by a terrible system of maternity care. Does that mean that I hate doulas or think they should be kicked out of hospitals? No. I just wish that maternity care in our country and our birth culture were such that women didn't them."

    I agree with you on this. I also agree that in an ideal situation, you shouldn't need birth plans because you'd know your care providers, they'd know you and your desires and preferences, and you'd receive mother- and baby-friendly care. So most of the stuff that people put on birth plans wouldn't be an issue anymore!

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  27. I'm going to agree with this awful doctor on a few small points. I myself am a doula, and a midwifery student. New to the provider end here is what I've seen...
    1. Many doulas make medical recommendations that they don't even fully realize they are making. Patient advocacy is a delicate thing and lots of them just don't get it.
    2. Doula's have training but it is brief. Claiming that DONA training is extensive and a year long is an exaggeration. I know because I've done it. Claiming to be a "birth expert", as some doulas do, is also not accurate.

    Lots of patients still just don't get what doulas are and I think many doulas (including myself at times in the past) have failed to explain this well enough. The public often conflates doulas with midwives. Patients often turn to doulas with medical questions. When doulas give answers from their own experience and background patients take this for medical advise.
    I think doula work and the reputation of doulas will improve with increased role clarity and patient advocacy education.
    A great phrase to emphasize is, "I provide physical and emotional support for families during labor."

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  28. Katie, I agree with you. I'm also a doula (www.getbabied.com) and while I am very clear with clients that I don't give medical advice, I get asked "what should I do" often at births. I try to encourage the client to ask her own questions of the doctor to get the information she needs to make an informed decision. So I say things like, "do you understand the risks & benefits?" "Do you have any questions about alternative solutions?" And so on.

    Here in austin we have a local professional association, centxdoulas.org, which is doing a great job of educating obs and nurses on what doulas actually do and how we're there to support the mama in her choices, not make choices for her. But there's still a lot of work to be done. I wish more obs and nurses understood that we can really make their jobs easier!

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  29. To me, the main value of a birth plan is in helping to ferret out the care provider's beliefs and ways of doing things. Ideally, then, the birth plan would be introduced and nailed down at the first meeting. I do not understand why a woman would choose a care provider that needed to be reminded on the day of birth itself that, say, she doesn't want an episiotomy. (That is, of course, assuming that she has a choice of care providers.) It is so nonsensical that I have to wonder if there are women who see doctors and midwives as just neutral parties who practice according to some arbitrary default, sort of like a webpage template?

    Meg, you're absolutely right. Which is exactly why so many doctors don't like them. If you're the sort of doctor who believes you're The Expert and that modern obstetrics is the pinnacle of birth science and wisdom, are you really going to be pleased with your patient making such a clear sign of dissent as using a doula as advocate, i.e. protection?

    I know that women use doulas even in homebirths, but in that case isn't the doula really filling more of a role of traditional midwife ("with woman")?

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  30. Ilan Stein told me that it would happen, but a little part of me did not believe her; now I do.

    I cannot prevent a cesearean or an episiotomy. What am I going to do? Knock over the instrument table? I wouldn't be admitted to the surgical room for a cesearean anyway, so no chance there. I don't understand why, if you are the pregnant patient, and you chose your Doctor, why I would be expected to stick my nose where it doesn't belong: medical decisions.

    My training is NOT medical. I am not a midwife, and I am NOT an OB.

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