The Issue with Hospital Provided Doulas

You’re sitting at a friend's table. Your ever expanding belly is, of course, the topic of conversation. “I’m thinking about hiring a doula”, you tell your friend. In the background the sounds of her own children serve as an unending, but joyful soundtrack. “OH!” she replies, “The hospital you’re delivering at provides a doula for anyone wanting them. They’re affordable, too. Maybe even free!”. Perfect, you think. Now, you can finally stop worrying about the money aspect. “Really? I’m impressed the hospital is providing them. That makes me feel so safe”, you tell your friend. “Isn’t it amazing!?”. You agree.

Pause a moment here and let’s consider a few things: Is it amazing? Or could it be problematic?

Let’s break down the conflict of interest before you grab the phone and hire that hospital provided doula. 

The Ethical Issue

The presence of a doula is supposed to ensure an unbiased, evidence based birth environment. When you hire a doula they work for you and you alone, but can this be true with hospital provided doulas? 

Honestly, no. 

Hospital doulas are often available for a small fee, or entirely free. This is because the hospital is paying them as a member of their staff, training them to follow hospital protocols, and as they receive this training they also learn their “DOs and DON’Ts”. Most likely those do’s and don'ts are vastly different from the ones followed by an independent doula. Hospital doulas don’t work for you and you alone. They work for the hospital. How often have you seen your labor and delivery staff stand up to your Dr. or call them out for practicing in a non evidence based way? It’s pretty rare, huh? This is the exact issue with hospital provided doulas. It is our job to follow your wishes as closely as safely possible and ensure that everything that goes on is 1.Consensual and 2. Appropriate care. How can hospital doulas truly do that when standing up for those things could get them fired, throw their family into a financial bind, and disrupt their career? Plain and simple- They can’t.

The Moral Issue

A doula is an extra set of eyes. A deeply-trained and highly-aware set of eyes that is watching and analyzing the care you receive as you labor and birth. We’re watching the pitocin level to make sure it isn’t being turned up too quickly (or without your consent), we’re watching for bags of Pitocin and making sure they aren't hung on your IV without your knowledge. We’re informing you that you don’t have to consent to a cervical check, we’re making sure you’re being asked before your body is touched. We are in all corners of the room, hearing the medical jargon and translating it within moments so that we can relay it to you in easy, digestible language. Our goal is ALWAYS to work in collaboration with your medical providers, but there are times when medical providers make moves that are not what you wish for, or in some cases not evidence-based suggestions for you and baby. In those situations we speak up. We have no obligation to your provider, hospital, nurses, etc… Our one and only job is to support you, advocate for you, and create an environment where you are in the driver’s seat of your birth. 

But what happens if your doula DOES have obligations to your provider, hospital, and nurses? Are they going to be as quick to speak up? Are they going to speak up at all? It’s unlikely. Speaking up for you, even when they 100% know they should, may get them in trouble. 

It might even cost them their job.

The Money Issue

While many doulas take HSA/FSA dollars, insurance companies don’t want to pay fair rates to provide their customers with doula support. Which means doula support isn’t accessible to parents with lower incomes, no HSA accounts, or parents who live paycheck to paycheck. Here is where the hospital swoops in to fill the gap and provide their patients with doulas that are paid through the hospital instead of paid privately. How wonderful that the hospital is providing this support! Sure, it looks good to the community. It looks so good, in fact, that it draws families in. 

Mother’s from all over the region are flocking to this hospital, and with them comes copious amounts of cash flow. Hospital doulas are not employed for your benefit--their position is a genius marketing ploy that fills the hospital’s pockets and fills you with a false sense of security. 

The Issue of Compliance

As we should all know by now, doctors, nurses, and other members of L&D staff are bound by hospital policies that are often not evidence based and/or overly restrictive towards physiological birth. 

Guess what! The hospital provided doula is no different. Here’s the best kept secret, hospital policy does not govern the patient body. Only consent does that. The hospital doesn’t want you to know that, of course, but one of the things I encourage my clients to do is get comfortable saying the phrase (or some iteration of) “My consent overrules your policy, and I do not consent to this”. I encourage my clients to get comfortable with it because my loyalty is to them and their wellbeing only. My wish is for them to bring their baby earthside safely and beautifully in charge. 

Independent doulas are not bound to policies and protocols and therefore they are not complicit in the routine dehumanization of mothers that may, and will at some point, take place on every labor and delivery ward. The doulas that work within these wards are bound by a contract. This contract outlines what they can and cannot do for their clients, and herein lies the root of the entire issue. Sure, epidural use drops slightly and breastfeeding rates go up marginally when hospital provided doulas are present for birth, but the fact of the matter is that hospital doulas aren’t empowering you to have the birth you want, they’re preparing you to give birth in a convenient and policy abiding fashion.

So, what control do you have?

Hire an independent doula. This may be a wonderful question for when you are interviewing for birth support-- “Do you work for any hospital system or only for private clients?” Any person you are hiring should be honest and transparent with you about any conflicts of interests. 

Now, this places the financial burden of hiring a doula on the parents, so we brainstormed a few ways to help fund your birth support:

• - Ask folks to put into a doula fund instead of buying a baby gift/baby shower gift
• - Find a doula who offers payment plans
• - Ask about cash discounts
• - Find a doula who offers sliding scale pricing
• - Barter with an offer that you can provide to your doula as exchange for their support
• - Add it to your baby registry
• - Ask your doula if they offer gift certificates for friends and family to purchase for you
• - Reduce the baby gear and ‘extras’ you invest in and instead invest in a doula
• - Save, Save, Save

The Bottom Line

Hospital provided doulas are almost always in this field for the right reasons, but unwittingly fall victim to the conveyor belt of birth all the same. They don’t take these opportunities to add to the ever growing birth trauma rate, but intentional or not, they are merely a pawn used to give patients enough of a false sense of security that they’ll flock from nearby cities and bring in more money. They’re used as a primer for medicalized birth so that you don’t come in informed, empowered, and aware of your rights. They’re used for good publicity and then bound by bureaucracy that impedes their ability to advocate, speak up, and do their job. 

Tie a person's livelihood to a contract that silences them and you’ll slowly see them become more and more complicit.

This is not a structure crafted to support physiological birth and achieve best clinical outcomes. This is a scheme crafted from hospital board rooms filled with (mostly) men that are more concerned with counting money in their pocket than they are counting the startling rate of trauma and deaths coming out of their labor and delivery wards. You are not a hospital provided doula’s boss.

That boardroom is their boss, and ultimately that is where their loyalty lies.