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Doulas and home birth: yes, they go together!

[Photo by Birth Becomes Her]

Doulas are most well known for their intervention-reduction potential.  Since cesareans and other interventions occur at very low rates in the homebirthing population, folks planning out-of-hospital births commonly believe that they don’t need a doula.  This is a reasonable assumption; after all, the risks doulas combat in the hospital (overuse of interventions, lack of privacy and autonomy, interruptions and harsh or hurried care from hospital staff) simply aren’t a problem at home.

But let’s take a closer look.

The doula’s main role is provision of emotional support and physical comfort during labor.  Families choosing home birth can certainly benefit from this – we can all use as much support as possible, no matter our birth location!   And when you consider that many women and families are choosing home birth because of a greater need for sensitive support than exists in the hospital, the doula becomes even more useful.  In addition to the extra appointments before and after the baby is born, who giving birth (especially drug-free in their home) would NOT want a dedicated support person to reassure them?

On closer examination though, there is another, less obvious, but very strong case for those choosing homebirth to get a doula:

The number one reason planned home births turn into hospital transfers is not the much-feared emergency, but rather, need for pain relief.

That’s right.  Especially for first time parents, the biggest risk of a homebirth is not a life-threatening complication, but rather having to pack up in the middle of labor and head to the very place you didn’t want to go, for an intervention you were trying to avoid — an epidural.  According to various studies, the risk is somewhere between 1 in 10 and 1 in 5 — this will differ midwife-to-midwife depending on the mix of first-time and repeat parents that her practice sees, but in general, the risk is not small.  Rarely, repeat parents may need an epidural, too, and even if not, there will certainly come a point in labor when they will feel overwhelmed.

So, if you have invested a large amount of time, money and energy into having an unmedicated delivery in the comfort of  your home, you should strongly consider a doula not just to stay comfortable and supported, but also to reduce the chances of transferring.  

Most women planning homebirths are confident in their ability to have an unmedicated birth and put in the work prenatally to ensure they are equipped with relaxation, hypnosis and other techniques to get through birth without pain relief.  And they should be confident — it is completely possible to have a lovely birth at home with the right mental preparation, and indeed, most families who plan a home birth do go on to have one.

However, it is important to understand that preparation is necessary, but not sufficient, for having a homebirth.  This is because factors beyond your mental fortitude, commitment to home as the place of delivery, and tolerance for pain are usually responsible for epidural transfers.  In particular, transfers for pain relief are often driven by a malpositioned baby.

Relevant here is that many doulas are trained in techniques to promote optimal fetal positioning, which can help combat the risk of non-emergent transfer.  A skilled doula will know how to spot signs that your baby is not well positioned for a comfortable delivery, and how to balance the patience and waiting necessary for a home birth with suggestions to promote fetal flexion and rotation. A knowledgeable doula can really be a gold mine in terms of transfer prevention. 

You may be thinking, “but isn’t my midwife going to help me through labor?” 

Midwives are certainly known for being much more present and helpful during labor than physicians.  And some midwives absolutely provide labor support in addition to their clinical responsibilities.  No doubt — having two heads to promote comfort and progress in labor is definitely better than one — especially if your midwife likes to be involved on the support side.  But just like in the hospital, there are a lot of reasons why you shouldn’t rely on your care provider to serve as your primary source of emotional and physical comfort during birth.

Homebirth midwives generally will not arrive until active labor is clearly established, meaning that you may be without any professional support for a large portion of your labor — especially if you experience a long latent or prodromal phase.  Its easy for folks to gloss over the importance of this time, since some don’t consider it “real labor”.  But its actually critical to stay comfortable and rested, especially if this phase turns out to be longer or more intense than expected — which is definitely what happens if the baby is less-than-optimally positioned.  The doula can be your support person during this time.

In addition, many homebirth midwives take a very non-invasive approach once they arrive: staying out of the way unless it is necessary to check fetal heart tones, maternal blood pressure or some other measure of well-being or progress.  Styles differ, but folks who plan homebirths are sometimes surprised how little they see their midwife during labor, who may be busying herself with such other tasks as setting up equipment, charting, speaking with her partner midwife, supervising a student, arranging childcare or rescheduling other appointments she had for that day.  Or, she may just be doing what midwives do best: sitting on her hands, staying vigilant and giving you space!  This approach has many benefits and goes to the heart of why so many choose home over hospital — yet, its easy to forget that this hallmark of homebirth midwifery is exactly why homebirthing families may want a doula to fill that gap.   Having a doula at your planned home birth allows you to reap the benefits of both models of care.

Finally, not all midwives are trained in or concerned about optimal fetal positioning.  Many understandably hold the view that there is a wide range of normal in birth, that a malpositioned baby manifesting in a difficult labor is not necessarily a problem, and that patience will eventually see the baby correct itself.  These things are all true.  Many babies are less-than-optimally positioned at some point during labor, and the majority of those will correct themselves.  Babies can also be born in less than ideal positions, for sure.  But it can help to have at least one member of the team who is trained to offer non-invasive, strategic actions to get your baby better aligned for an easier labor.  Otherwise, the alternative to waiting it out may become transferring for an epidural, in particular because persistently malpositioned babies tend to produce much harder labors than babies that are anterior.  Even second or third-time parents with one or more prior vaginal deliveries under their belt can find themselves struggling to overcome a posterior or deflexed baby.   Hiring a doula trained in Spinning Babies® can give you the best of both worlds: a midwife who won’t intervene unless medically necessary, and thoughtful labor support that can reduce your chances of preventable transfer.

About Diana Snyder

A former associate attorney at top New York and Boston law firms with six years of birth advocacy experience, Diana is the founder of Matrescence, a private doula service supporting women and families through birth and postpartum, and Birth Rights Solutions, a legal practice dedicated to women's rights in childbirth and the practice of midwifery. She is the architect of the landmark California lawsuit, Turbin v. Abbassi, in which mother and rape survivor Kimberly Turbin sued her obstetrician for battery following a 12-cut episiotomy performed after he berated her for saying, "No". Diana previously served as outside counsel to the Bay State Birth Coalition, a consumer organization advocating for legal recognition of certified professional midwives in Massachusetts, and helped author proposed legislation for CPM licensure in the Commonwealth. Today, she resides in Eastern Massachusetts with her husband Mike, son Bennett and beloved vizsla, Rocky.

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