Doula, Advocate, Activist

by Bonita Katz, BA, RN, ICCE, ICBD, IAT, CLC

Most of us in birth work are well aware of today’s controversies in maternal health care: high cesarean rates, increasing maternal mortality, inadequate informed consent/refusal, lack of personal autonomy, and the list goes on. These issues concern us – and they should.  We do this work because we care about mothers, babies, and their families.  And doulas are right in the middle of it all.  What is a doula’s role when a woman is in labor and it seems as though her wishes are not being honored? How does a doula advocate for her client? Before we answer those questions we must remember some facts:

  1. In most instances, the woman chose her care provider and her place of birth. While it is possible to change both of those while she is in labor, that rarely happens.  And who is to say that the next care provider or place of birth will be an improvement? Most of the time you will have to work in the place and with the providers that the woman has already chosen.
  2. The woman is in labor. If a doula chooses to blatantly disagree with the care the woman is receiving she forces the woman into a decision.  Either she must choose her medical care provider over the doula (thus compromising the support the doula could offer) or she must choose the doula over her care provider (and so compromise her relationship with those delivering medical care).

So what can a doula do?  Encourage the mother and her partner to ask questions.  This does two things: First, it validates the soon-to-be parents as adults responsible for their own care and the care of their child.  This is their baby and their birth.  This is a key component of family centered maternity care.  The family makes the decisions that are right for them. Secondly, their questions may be an indication to their care provider that they need to communicate more clearly. Improving communication not only benefits the family, but it also improves customer satisfaction scores for the birth facility. The doula herself can also ask questions. The recent update on doula care published by Evidence Based Birth (EBB) offers some welcome insight into client advocacy.  Good questions provide a way to ensure that the woman is aware of her options without negating the role of the healthcare provider. To quote the EBB article: “For example, if it looks like the provider is about to perform an episiotomy without the person’s consent: ‘Dr. Smith has scissors in his hand. Do you have any questions about what he is wanting to do with the scissors?’” Questions like this inform the woman (and her partner) and allows them to decide what to do with the information. Doulas can advocate in this way for their clients, but how do doulas address those major controversies mentioned at the beginning of this blog? We must make a distinction between advocacy and activism.  Both are necessary, but they are approached in very different ways and in different settings.  Advocacy is described above and defined in the EBB article as “supporting the birthing person in their right to make decisions about their own body and baby.” Activism is taking on one or more of the big issues, researching and publishing the facts, and educating the public. Advocacy may take place in a clinical setting while the woman is in labor, but that is not the place for activism. Doulas advocate for one woman at a time.  Activism addresses an issue that affects many women. Although a doula can be a birth activist, she must realize that activism may close some doors for her.  A birth facility may refuse her access if they do not appreciate her public stand on some issue.  Some have implied that birth workers must be activists in order to make effective change in maternal health care.  Activism will accomplish some change.  But so will the relationships that others build with health care providers.  The fact is that there are many ways to change the system.  We need activists… and we need advocates.  Let’s remember the difference and work within role we have chosen.


Dekker R (2017). Evidence on: Doulas. Evidence Based Birth. Retrieved August 23, 2017 from Katz B (2017) One doulas difficult dilemma. International Journal of Childbirth Education. 32(3), p. 6. 

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