Cesarean Awareness Month

cesarean awareness month

It’s #CesareanAwarenessMonth so I want to talk a bit about the discussion around cesarean rates and place of birth / chosen care providers.

I take some issue with this statement by Dr. Neel Shah (Director of the Harvard School for Public Health) in that if you’ve been attending births as long as I have, you can really start to understand why some hospitals have higher rates of surgical births than other.

There is a hospital in SF that is notorious for it’s induction and cesarean rates. The culture of the interactions between doctor and nurse, doctor and laboring person has at times been so hostile that many doulas refuse to take clients choosing to birth there. I am one of those doulas. I’ve seen too much there where I felt my clients were disrespected and put into unnecessarily risky situations, as well as overhearing some disturbing things while walking the halls among the doctors and nurses and no longer feel like my practice benefits from supporting pregnant folks seeking care at CPMC. I’ve lost a ton of potential working opportunities by sticking to my guns on this, believe me, but I felt my will to continue to do this work and the liability aspect of my practice suffer by attending births there. I never looked back.

I’m not the only one who has made this hard choice. The topic has come up with peers and it’s clearly a difficult one. Some doulas do very well in that hospital, they feel comfortable there, their clients are able to be treated well. Those doulas tend to have been working for a long time and are confident and outspoken in their normal lives, let alone in the birth space. I, however, don’t feel like it’s my role to have to fight every arbitrary decision being made for my clients around misused testing and labeling in pregnancy and the lightening speed toward interventions. At the end of the day, these folks chose where they are planning to give birth, chose their providers, and deserve bodily autonomy.

HOWEVER, despite not taking clients at this hospital, when folks email or call me for an interview and tell me they are planning to give birth at this hospital, I often spend some time talking about why I don’t take births there, rather than just funneling them along.

I can say the same things about pretty much every hospital and why the cesarean birth rate is too high (the tipping point is thought to be somewhere around 19% of all births), but there are definitely some practitioners and some hospitals where the outcome of a cesarean birth is much more likely. I feel like I owe it to my clients to be forthcoming about this.

Furthermore, I owe it to them to talk about the non-clinical reasons why most unnecessary cesareans occur, which start building LONG before the day of labor and have EVERYTHING to do with practitioners and where they get their care. If my client describes their visits with care providers with lots of, “well, they don’t ALLOW that,” or “I asked about X but they told me I had to do it anyway,” I don’t shy away from brining up that their care providers aren’t actually able to make them do or not do anything. Ultimately, my clients are in charge of their care and that of their fetus, so they should have the final say in refusing interventions, when they come into the hospital in labor, who is allowed in their room, what tests they may refuse, interventions they may refuse, firing nurses or doctors who make them feel uncomfortable and who’s decisions they don’t agree with, leaving the practice at any point in care, leaving the hospital if they don’t agree with the decisions being pushed on them, and what can and can’t happen to their baby after birth. Too often, doulas are the only gatekeepers to this important dialogue and unfortunately, we’re often the lowest rung on the ladder of care since we are non-clinical providers working with families often after they’ve gotten negative messaging from their clinical providers since conception.

Not all cesareans can or should be avoided, but there is a crisis in maternal care in this country and overuse of technology, interventions, and operations is a large part of the worsening picture. As doulas, we are obligated to speak up about the realities of why this happens. Too many doula trainings shy away from teaching newer doulas how to navigate these gray areas of scope. I do think it’s valid for us to stay within our physical scope of practice in terms of what we can do to help direct outcomes, but it is ABSOLUTELY our role to be forthcoming about systematic neglect of evidence and widespread abuse of role if we see it time and time again in certain places of care. More doulas need to be told this and we need to be more supportive of each other in navigating these tricky territories.

We are not magical talismans to ward off cesarean surgery if our clients are going to be told that their “high risk” from conception without good reasoning. It is not our job alone to protect our clients from unnecessary interventions — we guide them to the sources of empowerment, but they must ultimately empower themselves. And we must collectively empower one another to take the professionally risky move to speak up to our clients prenatally about the abuses we see. Remember that medical bullying often comes with a smile and a reminder that it’s the woman’s fault she’s high risk. We need to fight that language in our own practices and not shy away from telling the truth about certain places of birth.

More about my sleep training philosophy

I am really not on board with formal sleep training before 4 months at MINIMUM, but more likely 6 months. And even then, I only advocate for “cry it out” methods when there is some clear lack of thriving in one or more of the family members and only when other options have been exhausted.

ahhh the sleepy baby and his lovie

ahhh the sleepy baby and his lovie

What I'm offering is sleep education that actually has a strong focus on helping families put off sleep "training," understanding that it's not biologically appropriate and then explaining why, while still leaving them with some resources to hopefully get more rest. My sessions / classes focus on going over the basics of infant sleep patterns + cues and how feeding / digestion / overstimulation can affect these things. It's trying to cut out the stress around sleep by giving healthy and realistic expectations and some tricks for gentle sleep routines (that are often more for parents in the first months than a baby that can't be trained to notice anyhow). 

My hope is by helping families access high quality resources (versus opinion based books and blogs), have someone they can touch base with easily, and someone in home working with them one-on-one to help them understand their baby's unique patterns and needs, they can have a less stressful approach to sleep issues and can maybe avoid sleep training entirely. 

Honestly, I've talked every person who's contacted me about sleep training before 6 months out of it, so that feels good. Most families are starting some sort of drive toward scheduled sleep starting too early and it's a huge reason why I've started to do this education more since I was getting so many parents emailing me in pregnancy or with 2-3 week olds asking to be sleep trained.

Too many parents are getting bad intel about how you either need to get on the ball with scheduled and formal sleep training at such and such an age or else your baby will be developmentally stunted, not independent, a crappy sleeper, and stuck in your bed full of bad habits till their in middle school. There is not such a binary in the process of choosing what adjustments you want to make in getting babe sleeping longer and more independently. I want to be able to help guide parents through their options (not make decisions for them or tell them they’ve failed) so they feel intuitively connected to the needs and development of their children and confident that they’re making the most appropriate decisions for their own families.

If you are interested in getting some more education and support around infant sleep issues, there are a number of ways to access my care : Hourly consults, daytime observation and support packages, overnight observation and support packages, bringing me to a new parent group, or taking one of my longer courses. Check out my Infant Sleep Support page to learn more about each option.

…AND! I teach doulas about infant sleep basics, too! If you are part of a doula group or training organization and want to chat about these exciting and informative classes aimed at giving postpartum doulas more resources for supporting families through this minefield of misinformation, judgement, and anxiety please contact me.

cute picture. terrible swaddle. i have thoughts here.

cute picture. terrible swaddle. i have thoughts here.

Why do doulas cost so much?

Money is always a tricky subject, especially when working within a profession in the "healing arts." For many birth workers, this profession is seen as a "calling" as much as it is a job. Add to that the fact of these caretaker roles being traditionally held by women, being seen as "fringe" or outdated, and still sometimes viewed as a luxury item despite mounting evidence otherwise, and with no set national standardization for the profession a leaving a host of intricate and competing economic influences driving the fees for these services in every direction.

When I first started out as a doula, I was living in a community where bartering was the norm. In many ways, I really enjoyed that concept. There was always communal food, carpooling, couchsurfing, skill sharing, etc., and I learned a lot in my nine months there. On the other hand, I was making about $500 a month for a job I was way over qualified for and could barely pay my bills.

I was twenty-two, fairly fresh out of college and trying, desperately, to grow my doula business. I spent hours upon hours learning how the internet worked (funny, as I almost failed my web building class in college), calling every doula and “alternative” practitioner in town, forming study groups, forming community groups, volunteering at childbirth ed classes, and scrounging for clients, all with zero pay.

I was burnt out and exhausted before I even went to my first birth.

That first birth was wonderful. A home water birth with two midwives and my doula mentor. I did it on a trade and was happy to do so. I’m grateful for that experience and didn’t sweat not being paid.

After that first birth, I attended my next four births on a volunteer basis, too. What’s more, I had to travel 40 minutes to the hospital to attend them. Because it was through a volunteer program, I also had to drive up to the hospital numerous times for orientations and shots and the like, and often went in on night shifts only to leave after 12 hours without having attended a single birth.

Now, I’m not trying to complain or sound ungrateful, I got a lot out of each and every birth. Instead, what I’m trying to highlight is that this is not uncommon for a new doula. Not only do we have to invest several hundred, sometimes thousands of dollars to even start training to be a doula, but we are expected to attend several births for free. In my case, It was almost a year after my training till I got paid for my first birth. I was given only $350 for hours of travel, three prenatal visits, one month on-call, supporting the labor first at home then at the hospital, and two postpartum visits.

I moved out of that community after less than a year because I could not hack it on that rate. I traveled (by bike) south to San Francisco with the woman who was becoming my doula business partner, Jasmiene. We figured that if we could split the cost of owning a small business (and doulas are small business owners), and the time trying to acquire new clients, that we’d have a better chance of turning a profit and not getting burnt out.

The price tag for doulas in Olympia, WA was $300-450. In San Francisco and the surrounding area at the time I moved here and wrote this (around 2010) it was $800-1,500. Even with the increase in the cost of living, the rate at which doulas were being hired, how organized they were as a group, and how many opportunities there were to continue our education for a smaller fee made this move seem like a wise decision. We tenuously increased our rates to $800, but after just two births, we realized we were grossly underselling ourselves…plus we could barely pay rent on one birth a month. Eventually, we were up to $1,000 per birth and $25/hr postpartum ($30/hr for all night care). 

Now, $1,000 for a doula might seem totally ludicrous to some (and currently, it’s on the low end of the fee spectrum for doulas in the Bay Area), but I want to break it down into what the doula is putting into her services and what you are getting out of it:

Doulas are business owners:

  • In most cases, doulas are interviewing for new clients constantly. That means they are driving to you, either to your home or to a cafe, and spending money (on drinks and food and gas) and time to get about 1 out of 3-4 interviews ending in a hire. At one point in my career, Jasmiene and I were going to 2 or more interviews every week and shared no more than 6 clients in our practice at any time. More commonly, we had half that.

  • Advertising alone is an incredible financial burden and it’s often hit or miss. Printing business cards, pamphlets, flyers, advertising online, in newspapers, and keeping up a personal website really adds up. In the Bay Area, we were spending about 15% of each fee for these costs alone. If we took a hit one month or couldn’t take on more clients for some reason, those costs still existed. IT IS A BUSINESS.

  • Printing other materials is just as expensive. We always came to our prenatal visits with a wealth of information as well as necessary documents to fill out so we could be the best support persons possible. Contracts, hand outs, birth plans, favorite articles, readings specific to each pregnancy, etc. We weren’t employees of an office with a big, efficient printer, either. Every other month, we would go to the office supply store and buy several hundred dollars worth of printing materials ourselves. We also regularly had to go to a print shop to get things done more professionally and that cost really added up, despite having to do that maybe once every three months.

  • Despite having the same needs as many other small business owners and freelancers, since doulas are still considered to be working in a "fringe" field, it is rare that we would qualify for small business loans, adjustment programs, grants or scholarships for continuing education, tax credits, and other perks offered to small businesses in this country.

Doulas require continuing education:

  • Most parents are concerned about our credentials. Not only is it expensive to get and keep up with our certifications, most families are looking for women who are constantly continuing their birth education. These classes aren’t cheap. There are workshops starting at around $35 for a one-day session and they go up to $5,000 for courses offering a specific credential. This can often cause a catch-22 situation where it’s not always the “best” doulas (or the “best” doula FOR YOU) who is able to advance herself and her business, but rather the ones that can afford it and will thus generate more business and be able to get more clients.

  • Doulas often gather in collectives to help learn from one another and support one another. This takes up an extraordinary amount of time. Like it or not, time is money. We’re not paid hourly for the work we do outside of our interactions with clients and we’re not on a salary. Same for the amount of time we spend reading research articles, books, blogs, and discussing / debating this information with one another. If our collectives don't put money aside for subscriptions to various journals (and most can't afford to do it), those become out of pocket expenses, too.

What are you getting out off all those behind-the-scenes expenses anyway:

  • Doulas make themselves available for you. They cater their business to your birth. They are often the only ones there specifically for you and not for some outside agenda of profit, public health number, political pressures, hubris, etc.

  • Unless you are planning to work with a home birth midwife (and even then it’s not 100%), you will not get to choose the people who surround you in birth. How often have you heard of a friend telling you that she, of course, had the one doctor in the practice she’s never met before for her birth? You won’t meet the nurses before you deliver. You may be in labor during shift changes and wind up with eight different nurses and doctors before it’s time for baby to make her debut. The one constant you can have is a doula. Unless the birth goes on exceedingly long or the doula has to send in a backup for another dire reason, you will have that doula for the entirety of your labor. It makes an enormous difference in women’s views of their births to have a steady champion devoted to them and them alone during labor. We might be the only constant for you once baby is home, too.

  • Too few women understand how alone they will be in labor. Especially if you are in the hospital, you will only see your care providers for brief spurts of time to do this or that check in, routine intervention, etc., and then for the last few minutes of pushing. This can be daunting for women, and sometimes even more stressful for their partners, who will be made to be their only support persons in labor. I have come to labors when I felt it was too early because the woman and/or her partner really felt they needed me there. Sometimes, that’s meant having me sleep on the couch and occasionally popping up to tell them to relax and go back to sleep, that we’ve got a long way to go, and so on...but it often means giving up more than 24 hours of my life to make sure my clients are feeling safe and supported. Goodbye plans for grocery shopping. Goodbye friend’s birthday party. For doulas with children it can mean missing ballet recitals and art shows and more, but so it goes. We're hunkering down for the night because that’s our job as your doula, to be there for you and your partner when no one else can.

  • All that education and community building is what makes us your birth gurus in pregnancy and labor. Attendance at childbirth education classes is steadily declining, unfortunately. I can’t tell you how many times I’ve had prenatal visits run over 5 hours because parents felt totally unprepared. I don’t charge more for when these visits bleed out from 2.5 hours to 5 hours, either, just like we’re not paid more if a birth goes for 52 hours instead of 18. In so many cases, the sad truth is that your doula is the only person telling you some of this critical information. We will be the only people who will explain informed refusal, newborn procedures, and if that particular doctor is all too quick with a scapel. You are paying for the wisdom we are constantly trying to expand upon.

  • We are on call for you 24/7 for an entire month around your guess date. Being on call sucks. Ask any doula, midwife, or doctor and they’ll tell you the same thing: It’s the hardest part of the job. 99% of the time, it isn’t possible to be a doula and have a second job. With our $1,000+ price tag, after removing business costs and the rate for just the birth ($400 we figured), we were making a little less than $10 each on call day for each client. Now, you can’t take on too many clients with an on call schedule, either, so it was rare we’d have much overlap in pay during those on call weeks. How often do you live on $10 a day? Currently, that’s less than three gallons of gas, which is about how much I use for each prenatal and postpartum visit or interview. I bike as often as possible to avoid that, but it’s not always possible and relying on a bike for transportation has made clients of mine uncomfortable in the past. Doulas in most communities typically need to have cars to be on call, which is another huge cost.

  • We are there for you when baby comes home, too. We offer the same sort of tailored to you, one on one, in home care for birth person, baby, and family after the birth. That idea of seamless support we give in labor works the same magic during the postpartum period. You know us. You trust us. We were with you for one of the most monumental experiences in your life. That helps when it comes down to figuring out the myriad of details of being a new parent. We may be the only ones that notice marked changes in your mood and can stave off worsening postpartum mood disorders. We may be the only ones supporting your choices for feeding, sleeping, pacifiering, diapering, etc. Our community resources extend into the postpartum support community as well. We are often experts on breastfeeding and infant massage. We do your laundry. We hold your baby so you can shower or go for a walk. We talk you out of late night deep dives down the black holes of mommy blogs and their false alarms.

  • Studies show that this support reduces the need for all sorts of interventions, which in the end not only makes the experience more enjoyable and empowering for most laboring folks, but actually saves you money. Insurance doesn’t fully cover each and every intervention, so it can add up. Not to mention the rates of re-hospitalizations decrease with doula support. The average cost of a week in the NICU is $40,000. Makes $2,000 for the whole package seem like a bargain, no?

The sad truth is that our obstetrical care system does not fully support pregnant people and their families. We have recently dipped from 50th place in the world for maternal mortalities to 60th. Making the investment of hiring a doula does not form a magical protective shield around you in birth, but the studies point to numerous benefits to having this continuous support in pregnancy and early parenting. It is worth the investment in time and money to consider hiring a doula that suits your needs.

Here are some ways you can afford to hire a doula:

  1. Ask for part of the fee covered through baby shower gifts. Truthfully, you DO NOT NEED THAT MUCH BABY STUFF! If someone was going to spend $50 on baby clothes, that could easily go toward your doula fund instead.

  2. Ask your doula if they accept payment plans or work on a sliding scale but please keep in mind everything that she is putting in in order to be a great advocate for you and your baby.

  3. See if there are programs at your hospital, birth center, midwife practice, or community center that can help either connect you to a doula who works on a reduced budget, or one who’s fees are covered by a program or foundation. There are programs for young parents, homeless folks, recent immigrants, veterans, those without insurance, those with lower insurance coverage, high risk parents, and more in many communities, but it takes a bit of effort to find sometimes. Some church programs might have connections to these centering and doula groups, too.

  4. Consider hiring a newer doula. The studies show that working with any person who is there just for you, providing continuous support and encouragement in labor increases safety and satisfaction in the birth process. There are many benefits to working with a doula who has been practicing for a long time, but if they are out of your price range, you could potentially still get a lot out of hiring a recently trained doula for a fraction of the fee.

  5. Call your insurance agency and see if they will cover your doula costs. This may take calling and asking for several people at different times. It’s all about finding the person with the magic code, asking for specific details for what information you need to have laid out on your claim, and following through. Some doulas are well versed in how to write up their invoices to maximize coverage. If you have Medicaid in some states/cities, there is now growing insurance coverage, so it’s worth asking.

  6. Some midwives and birth centers offer discounts for working with doulas. Every so often, a doula will match that discount (I do!). That can save you upwards of $1000.

  7. Start putting aside money early in pregnancy for support like doulas, lactation consultants, acupuncturists, postpartum care, etc. Resist the urge to spend that money on needless things from Amazon Prime and think about the investment you are making into a smoother transition into new parenting.

I hope you found this rundown helpful in explaining the costs and benefits of working with a doula. If you want more advice around this decision, check out my site :