Doula Practice 101: How Practicing as a Doula Differs in Hospital Settings vs. Home Settings

By Jada Shapiro, founder of boober

With over 20 years of experience supporting new families, it’s safe to say that I’ve taken part in births in just about every setting you can imagine! Yes, even in a taxi!]. And while every hospital, birth center, and home is as unique as each birth, there are a few major differences you should be aware of, when it comes to how your work and care differ when supporting clients in a hospital setting versus at home. Though everyone seeks a safe and positive birth experience regardless of the setting, simply put, you cannot expect to have the same experience when supporting a doula client in a hospital as you would when supporting them at a homebirth. Being clear on the major differences can help you both avoid disappointment and frustration, and perhaps most importantly, can help you to be the best support person and advocate possible for your client.

Doulas Face Different Models of Care

In a hospital setting, you will almost always be working within the Obstetric Model of Care, a medically-led model of care with OBGYNs, who are surgeons, at the helm. Hospitals operate under the obstetric model of care with the assumption and overarching principle that birth is a medical event.  Hospital care is influenced by the threat of medical malpractice lawsuits and by the need to bill for all procedures in order to recoup maximum reimbursement from insurance companies, so hospital policies and practices are shaped by the anticipation of medical interventions.  In a home setting, on the other hand, the midwifery model of care centers the patient and operates under the principle that birth is a normal, life event that requires intervention only when safety is compromised or at risk. Midwifery care assumes that birth is a healthy part of a person’s life and the care tends to be more patient, in order to minimize interruptions and interventions that could interfere with the natural birth process.

Doulas May Encounter Different Levels of Resistance

When you first meet your client, it is common to discuss all of their hopes and wishes for their delivery so that you can support them in helping their vision for birth come to fruition. This eventually becomes the birthing person’s “birth plan” or birth preferences, which you will work to see honored, regardless of the birth setting. Knowing that birth rarely goes according to plan, one of your jobs as a doula is to help your client navigate the process in an informed way, so that if aspects of their birth veer from their expectations, you can help them acquire the information they will need to make the best decision for themselves. Whereas in a home or birth center birth, the doula is an expected and fully accepted part of the team, in a hospital, you may encounter resistance from the medical staff who may be less familiar with doula care or may have a more authoritative and less collaborative approach. , In many places, doctors and nurses are increasingly open to the idea of doula support during labor and delivery, as they learn about the benefits of doula care and as ACOG has endorsed the use of birth doulas during labor. Ultimately, it depends on the individual care providers and places of birth.

Doulas May Have to Translate to Differing Degrees

Advocacy and helping your birth clients understand their choices and options is one of the many important roles of a doula. At a planned homebirth, the birthing person, support people including doulas and other family working together in a patient-centered model. Typically, although not always, the midwife and the parent are aligned in a 1:1 setting. Unlike in a homebirth, in the hospital, this may mean acting as a liaison between your client and the providers in a much more active way than you would need to in a homebirth. When working in a hospital setting, your client will likely come in contact with a large number of medical and general hospital staff. You may need to translate the medical language that they use, explain medical procedures the staff might mention without explaining enough for your client to understand, and ask, or help your client ask the questions, that will allow them to give true informed consent.

Doulas May Offer Different Types of Support

Regardless of the setting, the emotional and physical support you provide to your doula client will be crucial through the intense process of childbirth. In a hospital setting, your clients are much more likely to have higher rates of intervention, so you may be supporting a client through a planned or emergency c-section, a medical induction, or the use of an epidural, none of which would be present in a home or birth center birth that doesn’t include a transfer. At home or at a birth center birth, your support may be a much more physical and mobile process since the person will not have any access to major pain medications. This is not to say that in the hospital you will be sitting back and relaxing! Some doulas report having to be much more engaged during hospital births, than home births, as the physical and emotional stressors that can accompany a hospital birth, may necessitate more “intervention” on the part of the doula. You may also support birthing parents who have an intervention, epidural-free labor at the hospital, which may mean that you will be providing a lot of Non-pharmacological pain management support in addition to potentially using positions that are rarer in hospital settings. Therefore the doula working in the hospital with an unmedicated birthing person must also navigate potential comments, judgment, or surprises from the hospital staff which is less well-versed in these techniques. In a homebirth, you may be called upon to be more helpful overall, from helping the midwife

No matter the location or situation, doulas provide essential emotional and physical support to a birthing person in a way that most doctors, nurses, and midwives cannot because they are focused on providing medical and clinical care. Even so, it is worthwhile to consider the differences between these birthing settings before taking on clients or to prepare yourself and temper your expectations as you go into birth.