Labor Doula’s Scope of Practice

Recently on one of the facebook doula business sites the question arose as to which organization the birth professionals were aligned with either by training or by certification. Some birth professionals stated they were not certified because they did not want to be limited by the scopes of practice of any organization. This statement can cause some speculation that may be misunderstood.

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I am certified and a member in good standing with CAPPA. Their scope of practice is spelled out clearly for each of the areas they certify.  It is pretty clear when it says, ” It is not within the labor doula’s scope of practice to offer medical advice or perform any medical or clinical procedure.” It is important also to note- “it is outside the scope of practice for the CAPPA Labor Doula to attend births that are intentionally unassisted.” Meaning that a midwife or doctor needs to be available or planned to be present.

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I used to also be dual certified with DONA. I chose to let that certification go due to redundancy of certifications and the support level I was receiving from CAPPA instead. But their scope of practice is very similar. They state, “doulas do not “prescribe” treatment, any suggestions or information provided within the role of the doula must be done with the proviso that the
doula advises her client to check with her primary care provider before using any application. ” And “the advocacy role does not include the doula speaking instead of the client or making decisions for the client. The advocacy role is best described as support, information, and mediation or negotiation.” But where their scope gets really limited is in additional publications like an article by Penny Simkin for instance on aromatherapy. Here it is stated that  there are seven questions that must be considered:

1. Are there claims of specific medicinal or healing benefits from the “remedy” (as opposed to soothing a normal pregnancy or labor discomfort) or claims to correct or cure an abnormality?
2. Are there any possible harmful side-effects?
3. Does the action or advice on this subject require special training, certification, or extra education to ensure safety and proper application?
4. Does the remedy usually require a prescription or supervision of a trained clinician?
5. Is the subject for which you are giving advice usually covered by a doctor, midwife, or maternity nurse?
6. Might your advice conflict with that of your client’s clinical care provider?
7. Might your action or advice worsen the relationship between your client and her caregiver?
If the answers to all the above questions are “No,” then the action or advice is probably acceptable within the doula’s scope of practice. If the answer to one or more question is
“Yes,” then you should not do it.

There are doulas with extra skills that they have learned elsewhere. Perhaps they are also massage therapists, or have trained in acupressure or rebozo techniques. Or perhaps they have taken some additional training in aromatherapy and essential oils. And there are those who have been or are also midwifery assistants with training in neonatal resuscitation or fetal monitoring. When they use these additional skills, they may be stepping outside of their scope of practice or they could just be wearing a different hat in your labor support than what you hired them for.  But one of the things you need to ask is do they plan to wear that hat in your labor? Do you desire for them to do so? Do you need them to do so? For instance if you are having a home birth, will the midwife have an apprentice or assistant that provides some of those more midwifery skills? If you are having a hospital birth, would any of those “outside of a doula’s scope” skills really be used?

I was casually chatting with a new midwife recently. She said that some doulas seem to think there is a fine line between being a doula and being a monitrice. A monitrice according to the free dictionary states that a monitrice is “a labor coach, usually a registered nurse, who is specially trained in the Lamaze method of childbirth. The coach provides emotional support and leads the mother through labor and delivery, using the specific techniques for breathing, concentration, and massage taught by the Lamaze method in classes for the psychophysical preparation for childbirth.” but this is not correct at all! And this may be why there needs to be a bigger line between the jobs of a doula and a monitrice. You should not trust all you read on the internet for sure! Here is a better explanation: “A monitrice’s primary role is that of labor support. Just like a doula, a monitrice offers continuous, hands-on support during labor. Unlike a doula, whose scope of practice generally prevents her from providing any clinical services (by their certifying organizations), a monitrice will perform limited clinical assessments such as monitoring the baby’s heart rate during labor, mom’s vital signs, and assessing cervical dilation.” Often a monitrice is a midwife who offers herself to women as labor support.

I think that is a huge divide in services. As a doula I do not perform any clinical assessment. I have knowledge of some clinical tools since I have been a doula for two decades and attended 600 births, but I do not want to mislead anyone in thinking that hiring me or one of my doulas who may have additional training, that we plan to use that training in your labor support. In fact, it could be quite misleading to share the knowledge or skills I have if I do not plan nor agree to offer those skills when you hire me as your doula. In our company we feel there is a huge divide between a doula and a monitrice.

We are all either trained or certified with a national or international organization. I have only shared the two most known organizations. Please look at our doulas skills and realize we stay within our scope of practice.  If we are using tools outside of the tools taught in a doula’s initial training, you can be sure we have had additional training to do so. But also know that we do not step outside of our role as a labor doula in doing so.