TheFeministBreeder posted a great blog the other day about her initial impression of what a doula was, and how that changed when she met the doula for her second birth.

I was reading and nodding along, especially when I read this line:

“ I realized not only that doulas are real professionals with real skills, but many of them weren’t at all what I had pictured in my mind.”

Later in the post she mentions cost, though.  And she offers up advice that I have seen (and even given, in the past) on many email lists and message boards:

“So now you know WHY you should hire a doula, but maybe you think you can’t afford it. Not true! There’s a doula for every budget.  Check into community-run doula programs or volunteer programs.  Ask local childbirth educators if they know any doulas who are in the process of certifying – they may work for free or at a minimal cost.  Many highly experienced doulas even work on a sliding scale or a payment plan.  In most cases, you just have to ask.”

Indeed, one of the big doula certifying organizations even has community service doula work as a part of their Code of Ethics

“Community Service
The doula is encouraged to assist the DONA International vision of “A Doula For Every Woman Who Wants One” by making reduced cost or no cost labor support services available when possible.”

But does this mean that every woman should have a low cost or free doula?  Think about a food bank – that food is there donated by those who have more, to help those who have less.  Would you go to a food bank to get free food if you really didn’t NEED free food?  Would you go just because maybe there are other things you would rather buy than food right now, even though you have the money? For most people, the answer is probably “no”.  Yet more and more I am seeing women say that they want a doula, but they don’t want to pay full price.

If you are considering hiring a doula, think about the reasons why.  Women who have doula assistance at their births have lower rates of interventions and cesareans, and higher rates of natural birth (if that is what they desire – doulas aren’t only for women who want natural births).   Ask women who have given birth with one how they feel about it and you will hear things like “at that moment we would have paid her double her fee” or “she was worth every penny” or “she was worth her weight in gold”.

There are many items in the course of a lifetime that people will budget for, but a doula isn’t always high on the list.  The average cost of a wedding cake is $543.  Is a doula worth as much as a wedding cake?  I would say much, much more.    During pregnancy a doula is there to answer questions, point you to resources, and acknowledge and calm the fears and stresses that can accompany the end of pregnancy.  In labor, the doula offers comfort techniques, both physical and mental, as well as information to help navigate the choices that you will face and help you achieve the best possible outcome and experience.

When a doula goes “on call” for your birth, she is saying that for several weeks, she is willing to drop anything at a moment’s notice to come to your birth.  That includes everything from not planning vacations during that time, being willing to leave a family event, or even be interrupted during an intimate moment.  Every night your doula checks her phone to make sure it’s on and charged, maybe even calls it to make sure it’s working (not that I have ever done that…).  She finds a skilled peer to act as backup in case an illness or emergency mean that she has to miss your birth, and if she has kids, she puts together lists of people who can watch her children on short notice.

So when you think about hiring a doula, and you think about how much you are willing to pay, think about all of that too.  Yes, there are doulas who are willing to work for a lower fee, or donate births.  But remember that “doulas are real professionals with real skills” and they deserve to be paid for the work that they do!

If you really truly cannot afford a doula, there are definitely avenues of help available to you.  For more information on how to find a certifying doula, contact the Georgia Birth Network.

Despite repeated calls, we couldn’t get any news coverage.  Apparently people enjoying the various festivals around town this weekend is more interesting than maternal and fetal health.  Did you know that Georgia is dead last in the US for maternal mortality?

The location we chose this year was Piedmont Hospital, which has the 2nd highest c-section rate in Atlanta.  A representative from the hospital contactedICAN of Atlanta and the Georgia Birth Network to let us know they were aware of the rally, and wanted to be part of this “positive message sent to the women of Atlanta”.  She attached an article that Piedmont’s Chair for Women’s and Newborns Services was interviewed for, suggesting that we might distribute it at the rally, and that it did “a great job of discussing the pros and cons of VBACs”.

Here is the article – VBAC risks and benefits: Is vaginal birth possible after a C-section?

By the title and her description, it sounds like a great article discussing both sides of VBAC vs. elective repeat cesarean section (ERCS), right?  The problem is that if you read the article, you will see that it is not.  Not even close.  The article starts off quoting a recent study about the safety of VBAMC (vaginal birth after multiple cesareans), in this case 3 or more.  While this was a very encouraging study, it isn’t the best one to use in an article about VBAC.  There are many other studies demonstrating the safety of VBAC.  In fact the National Institute of Health concluded at their recent Consensus Development Conference on Vaginal Birth After Cesarean that:

Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision.

Going back to the article, we would expect to see some of the risks and benefits of VBAC laid out in the section titled “Risks and benefits of a VBAC” (or am I crazy here?).  Instead what we find are “numerous risks for a woman attempting a vaginal birth after one or more C-sections” listed.  The entire section on risks and benefits does not list a single benefit to a VBAC – or a single risk of ERCS.  (For the record, some of those risks are infection, hemorrhage, injury to organs, adhesions, hysterectomy, secondary infertility, risks to future pregnancies such as ectopic pregnancy, placenta previa, accreta, and percreta, and uterine rupture).

Later in the article, a few risks of increasing cesareans are mentioned, but only in the context of how much MORE risky they would make attempting a VBAC after 3 cesareans.  I’m really not sure why they are focusing so much on the VBAMC issue and study, when the article isn’t supposed to be about that.

Harry M. McFarling, III, M.D., the Piedmont physician who was touted as doing a great job discussing the pros and cons, instead offers this reason for why the mother might choose an elective repeat cesarean:

A mother with another child at home, for instance, may choose the predictability of a scheduled C-section.

While I’m sure that some mothers might choose this, for some it may be more important to try for the probability of a shorter recovery so that they can take care of their other children.  Or it may be more important to them to choose the option that presents a smaller risk of them dying, another risk that the article does not list.

McFarling also says that the reason for the first cesarean is key.

If it was due to failure to progress, if baby was too large or pelvis too small her risk would be greater than, say, a woman who had a C-section for another obstetrical problem that didn’t involve failure to progress in a previous labor.

There are studies showing that if the reason for the previous cesarean was failure to progress (FTP) or cephelopelvic disproportion (CPD aka “baby too big/pelvis too small), the chance of a successful VBAC may be lower.  But NOT that the risks of attempting a VBAC is increased.  And both FTP and CPD are diagnoses that are not cut and dried.  Was failure to progress possibly due to the mother being induced with a low Bishop Score?  Or being confined to the bed instead of utilizing upright positions?  How long before they declared the labor to have failed to progress?  The inability of a baby to fit through the pelvis could also be for many reasons.  Was the baby in the optimal position to fit through the pelvis?  Was the mother allowed to push in a position that helps the pelvis open up more?  Even if the baby was truly too big to fit (which is quite rare), is there any reason to believe that a future baby won’t?  Every pregnancy and every baby is different.

The article ends with this gem:

Ultimately, McFarling says, a VBAC is something a mother needs to discuss with her doctor. “Together they can weigh the risks and options to help mom make the best decision for herself and her family.”

The risks and options.  Not BENEFITS, because according to this article, there are none.  This article is crap. And that’s using a nicer term than I normally would 

The decision to attempt a VBAC can be a difficult one, but it should be made with real informed consent.  If you are looking for evidence-based information on VBAC vs. ERCS, Childbirth Connection has a very thorough section on VBAC or Repeat Section.

There were hundreds of cars that drove by the rally location, hopefully our signs spurred some conversation or got them thinking about their options.