What is a Doula?

Greater Houston Midwives’ Alliance Position Paper:
The Scope of Practice of Midwives and Doulas

In the interest of providing the safest maternity care possible, consumers need to know all they can about the scope of practice of their providers. This position paper was created by the Greater Houston Midwives’ Alliance (GHMA) to educate the public of the differences between midwives and doulas.

In the state of Texas, there are two types of midwives: Licensed Midwives, supervised by the Texas Department of Licensing and Regulation (often certified through the North American Registry of Midwives (NARM) as Certified Professional Midwives- CPMs), and Certified Nurse-Midwives (CNMs), supervised by the Texas Board of Nursing. While there are differences in training and scope of practice, all midwives serve as primary care providers to low-risk clients through pregnancy, labor, delivery, and postpartum, as well as to their low risk newborns during the first few weeks following birth. In this capacity, a midwife follows routine laboratory and ultrasound protocols, performs regular prenatal exams, educates clients on health and wellness, and collaborates with other medical professionals if complications arise. Midwives are required to be trained and maintain certification in CPR and Neonatal Resuscitation. These certifications are renewed every two years. Licensed and Certified Nurse-Midwives have access to the Texas Electronic Vital Events Register (TxEVER) to file birth certificates and apply for social security cards. Most midwives also have access to medications and are trained on how to use these medications in case of complications such as postpartum hemorrhage.

In contrast, a doula is a support professional who assists her client emotionally, physically, and educationally before, during, and after birth. They provide a vital service to women who want an advocate and personal care in labor, especially in a hospital setting where their experience is invaluable. As there is no licensure or legal criteria to qualify as a doula, the range of training and services offered is varied. However, doulas do not have the legal authority to perform clinical assessments or tasks. While frequently well trained and experienced, it is not their role to identify complications or facilitate delivery. To perform clinical tasks without being licensed by either the Texas Department of Licensure and Regulation or the  Texas Board of Nursing, even if licensed in another state, is considered practicing midwifery without a license.

With the onset of COVID-19 in early 2020, many families are seeking out alternatives to the hospital environment. The members of GHMA have noticed an increase in pregnant people considering unassisted birth (also sometimes called free birth). Unassisted birth describes birth with no supervision by a licensed care provider. This choice may be for religious reasons, philosophical reasons, prior experiences with medical care or childbirth, or a desire to avoid over-medicalized management of their birth. No matter the reason, it is an individual’s right to choose the birth location and attendants, but it is also the responsibility of the pregnant individual to be fully informed. A trained midwife is an expert in normal, low-risk birth, and hiring a midwife to attend your birth affords you current information on the wellbeing of your baby and yourself. Any birth can result in sudden complications, whether at home, a birth center,or a hospital. A midwife will have varying experiences with what can go wrong during birth, what are variations of normal, and corrective measures that can be safely made in a community or out of hospital setting. A midwife is trained to recognize when needs change and a higher level of care may be required. The studies supporting the safety of out of hospital birth have one important criterion in place: that they are attended by a trained care provider. We acknowledge the variety of reasons a family may choose unassisted birth but assert that the presence of a doula at an otherwise unassisted birth changes the dynamics. The doula becomes the most experienced person present. Even if she clearly stays within her scope and does not perform clinical tasks, if a complication were to arise then she may be subconsciously looked upon as the authority to determine what is normal without adequate training or legal ground for doing so. We urge pregnant families to carefully consider how a difficult situation such as a severe postpartum hemorrhage or a newborn needing resuscitation would be handled.

There are many wonderful midwives and doulas in the Greater Houston area. When you set up consultations and interviews with your prospective birth team, we suggest you ask and consider the answers to the following questions, in addition to considering geographic location and personality.

When interviewing a midwife:

• How many years have you been practicing?
• At how many births have you been the primary midwife?
• What was your midwifery training and what continuing education have you undergone?
• What is your protocol in case my risks change and I need to transfer care during my pregnancy?
• What is your protocol for non-emergency and emergency transfers during labor?
• Who will be at my birth?
• What kinds of equipment and medications do you bring to the birth?
• Do you have any testimonials I can read or former clients who I can talk to?
• Who is your backup in case you are at another birth when I am in labor?
• How do you handle postpartum hemorrhage?
• How can you help if my baby needs resuscitation after birth?
• Do you repair vaginal tears?
When interviewing a doula:
• What kind of doula training did you undergo?
• How many births have you attended?
• At which settings (home, birth center, hospital) do you attend births?
• What is your birth philosophy?
• What kinds of support do you offer me during my pregnancy?
• What kinds of support do you offer during labor?
• Do you have any testimonials I can read or former clients who I can talk to?
• Who is your backup in case you are at another birth when I’m in labor?
More information about midwives and doulas in our region can be found at the following links:
Texas Department of Licensing and Regulation: https://www.tdlr.texas.gov/midwives/
Texas Board of Nursing: https://www.bon.texas.gov/
Greater Houston Midwives’ Alliance: https://houstonmidwives.org/
Association of Texas Midwives: https://www.texasmidwives.com/
Doula Match: https://www.doulamatch.net/

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