Setting and keeping boundaries.
I have practiced as a doula since 1991 and as a midwife since 1999. I have not yet experienced burnout, and I love my work as much as I ever have; every birth is new and exciting for me. Not only is this because I am fortunate to have found the work I love, but I have also set clear boundaries with my clients throughout my career, starting from the very first client meeting.
The Initial Consultation
When you meet a client for the first time, you, the doula, set the tone of your relationship. If you are dressed in a warm, yet professional way, you let the client know that this is a business for you, even if you have not yet charged any fees. In my practice the initial consultation is free to allow the prospective client to meet me and see if she likes me and the way I practice before making any commitment. It's also a chance for me to screen her for potential problems, including the ability to pay. While I may choose to be her doula pro bono I want it to be my choice, not a result of her failure to pay. I have several documents that I bring to each initial consultation: a fee agreement, an informed consent, an information sheet, and a history form. These forms and the conversations they elicit establish the basis of the relationship that I create with my client and her partner, but I never open up a visit by first going over paperwork. Be friendly and warm and open your conversation by asking the parents for their questions and listening carefully to their concerns. Often the natural flow of the conversation will allow an easy opening for you to introduce the paperwork.
This document tells the client who you are and what your level of experience and training is. It also tells the client what her responsibilities are. I use a one page document that also informs my clients that I can make no guarantees as to the outcome of the birth but that I will do everything in my power to help her have the birth experience she hopes for.
This document outlines what is included in the fee. It should be clear about the number of pre- and post-natal visits, what is included in the birth care, and when payment is due. I state that my on-call time is included in the fee. Look at this document as a way to let your clients know what they are paying for and what they will receive in return. Of all my documents, this is the most important in setting boundaries. Once I have clearly outlined the services I provide, clients are very respectful of the boundaries I have set. Because I have had few clients who spend a lot of time on the phone my fee agreement states clearly that unlimited phone time is included. This particular policy may vary from one birth professional to another, so I make sure my clients are clear about my own policy.
This tells the client how to get in touch with me. It includes all of my numbers (pager, cell, and home) and which to try first. I include a sentence that says "for routine, non-emergency concerns, please call between 9:00 am and 9:00 pro. If you are in labor or experiencing an emergency, please call any time, day or night." This sentence is another way that I draw clear boundaries. I don't want to be woken up late at night for the normal aches and pains of pregnancy or to reschedule an appointment. I also don't want client time to interfere too much with family time, so I try to keep conversations short when my husband and kids are home. My information sheet also contains a list of warning signs and normal labor signs. As with all of my documents, I don't just hand it to the client, but I actually go over it with them.
Having established boundaries with the informed consent, fee agreement and information sheet, I've set the tone for the rest of the relationship. Only rarely will a client strain my boundaries after I've set them carefully. But if, despite your warm, caring, but clear boundary setting, you still have a client whose needs are causing you to feel overstretched, what can you do?
Emotionally Needy Clients
An emotionally needy client may be someone who worries excessively about the details of her birth or about her health; she may be lonely and have few relationships that meet her emotional needs, or she may be going through a crisis that makes her less secure. She may try to use her doula to fill some of her emotional needs, and she may call and want to talk for long periods of time or want more prenatal visits than your contract includes.
If you provide unlimited phone calls as I do, you may have a challenge. If a woman is calling you frequently and talking for long periods of time, you may have several options. You can screen calls with your answering machine or caller ID and call her back at your convenience. When you call her, you can let her know that you only have a few minutes to talk and ask her "what's up?" I find this question elicits a more specific response than "How are you?" If she's someone who goes off on tangents, try to keep her on point. She may be bored, lonely, or depressed. If so, let her know about new mom groups, La Leche League meetings, or any other groups she can join, and don't hesitate to refer her to a qualified therapist. Be her doula, not her counselor.
She may have real health concerns that are not being recognized by her provider. Ask if she's talked to her doctor or midwife, and remind her that, as a doula, you can't give out healthcare advice, but support her in finding a way to have her needs addressed. You may say something like "You've brought this up before and it doesn't sound like you're getting what you need to make it better. What do you think would be helpful? Would you like me to help you find other resources for this problem?" If she has a concern that seems urgent, encourage her to get help immediately. If she has a problem that seems emergent tell her to call 911; you can meet her at the hospital and offer support.
If she wants extra visits, charge her for each visit beyond the original agreement. I include 3 prenatal visits and two post-partum visits in my fee. Beyond that I charge $25.00 per visit, payable at the time of the visit. If she asks for extra visits, let her know you'll be charging for them. If you're not yet charging for your doula care, decide ahead of time how you would handle the situation and have a policy that you stick to. For instance you could include a specified number of visits that you include when you waive your fee, but after that you need to charge a certain amount. Although you may have an emotionally needy client, it is not your responsibility to meet all of her needs, and you shouldn't, particularly if her needs require professional intervention.
Financially Challenged Clients
New doulas who work for free often work with women who have limited support. These women may be in a committed relationship or single; they can be from all walks of life. Lower income clients whose needs may be very basic and more pressing can cause a doula stress not only because she cares about her clients, but because she tries to fulfill too many of those needs herself. If a mom you are working with has issues with basic needs such as food and shelter or is experiencing severe financial strain, you may feel compelled to help. This is good, we want to help people; but we have to do it in a way that doesn't cause burnout for us, our families, or our other work.
Decide what you can and can't do as you listen to a woman's story for the first time. Think about the services you have defined and what you provide other clients. You are here for the birth. Being kind and supportive throughout her pregnancy and labor is a good thing that goes a long way. If you can and want to help with needs such as transportation or phone calls, try to combine it with a doula visit or other errands of your own. You can bring a meal after the baby comes or give groceries as a baby present. Again, avoiding burnout is the key to having a long career and helping more women. If you allow a client to come to rely on you as a source of food or financial or psychological support, or if you repeatedly perform above and beyond your defined services, you may strain your energy and the tolerance of your other relationships to a dangerous point. Going beyond the limits of your own finances or your family's tolerance will definitely cause problems for you in other relationships.
If you are working with a client who needs, but is not receiving, social services, it would be appropriate, with her permission, to call her primary caregiver and help her get the services she needs. If she has unexpected bills, Medicaid may be retroactive in her state, paying pregnancy-related bills already incurred, even after the birth.
If severe financial challenges occur with pregnant women who are in committed relationships, not only might these women need social services to help them get through these challenges, but the financial strain might cause a strain within their relationship. You may want to help the couple find a counselor who will work with them on a pro bono basis. Don't provide counseling yourself even if you're qualified to do so. It mucks things up too much to be the doula and the relationship counselor.
Many single women who become pregnant plan to do so and have financial and social resources to support them through the pregnancy. These women will be likely to seek out and pay for doula services because they want the care and emotional support that a doula provides.
Some single mothers may be financially challenged as well and you may need to support them as you would any other mother with similar concerns. Single morns are more likely to be lower income and feel isolated during their pregnancy. They really need doula support.
When a client with whom you've been working develops medical issues in her pregnancy she will need your support more that ever. It will be tempting to clean her house, make her meals, watch her other kids, and generally do whatever you can to help her. Take a step back and think about her resources. Are there other people in the community who can help? If she belongs to a religious community, there will often be a committee that takes care of meals for people with pressing medical needs. If she has a close group of friends, belongs to a play group, or has been going to childbirth classes these groups can provide support. In this situation the role of the doula is to ask her what she needs and help her find ways to meet those needs but NOT to meet all the needs yourself. So you can ask her if she's contacted her pastor or rabbi if she's a church or synagogue member. You can ask her if she has relatives who are able to help. If she'd like you to help at home, you can charge her for it at a rate similar to a post-partum doula. You can offer to help organize meals to be brought to her. If she gives you a list of people you can call for meals, make the phone calls, include yourself for one meal, but don't feel like you have to do it all.
When a woman develops a medical condition that complicates her pregnancy, she needs a lot of information. I enjoy researching this kind of information, so I will often volunteer to do so and share it with my client. Indeed, providing information and resources is part of what most doulas do, and it's a great way to get continuing education credit (if you document your research).
Fetal Demise/Stillbirth/Newborn Death
This is a time to pull out all the stops. Be ready and available to listen, hold your client's hand and go over the birth as much as you can without straining your other relationships unduly. For a week you'll be spending lots of time with the family, if they want you to, and for the next several months you may be spending a lot of time listening to the mother. As long as you are helping the mother access resources appropriately and you aren't trying to do things you aren't trained to do, ask for the understanding of your loved ones for a short period of time. You won't be in this situation often, so you can be assured that this is a rare occurrence that may not happen again for many years. Take care of yourself by finding a safe, confidential outlet for your own feelings of loss and sorrow.
Setting appropriate relationship boundaries is like maintaining your car. With proper care and attention to your doula relationships you will have many happy years of supporting and guiding women through labor, and setting limits will help empower your clients. Just as you model and guide a woman's breathing in labor, you can model and guide her in her relationships with others.
by Nancy Draznin, ALACE Labor Assistant Workshop Instructor
Nancy Draznin is an ALACE Certified Labor Assistant and Childbirth Educator and teaches ALA CE Labor Assistant Workshops. She is also a homebirth midwife. She lives in Genessee, Idaho with her husband and three children.