Three images of the same woman in a different hat

The Problem With Imaginary Hats

The argument comes up often when doulas are discussing scope of practice. When doulas who are also midwifery students talk about doing clinical things at births, you hear things like this:

Woman juggling a variety of different hats

“Some doulas also have midwifery training and therefore have the ability to perform some medical support, but caution must be used! If such a doula is offering a client “doula services”, the medical care is out of SOP unless she changes hats.”

“If I carry and use Clary Sage essential oils in my birth bag to encourage stronger contractions, I’m doing it under my doTerra Rep hat, not my doula hat.”

“I can do whatever I want at births, I just switch hats to whichever one is best suited to what mom needs.”

I’d love to actually SEE one of these mythical hats. Because that’s the huge problem with these imaginary hats – no one can see them!

This leaves parents and providers with the impression that you don’t follow scope. In your head, you are doing mental gymnastics and swapping hats. But to your client and the providers working with you, there are no “hats” – you’re just the doula, doing things outside of doula scope.

Let’s talk about some examples:

Example 1: Tereza is an experienced doula who has just begun the process to become a home birth midwife. She is attending a birth alongside a midwife friend Tereza hopes will be her preceptor as she learns midwifery. During the birth, the midwife offers to let Tereza do a vaginal exam, and the birthing parent agrees to allow that. It would be Tereza’s first clinical exam. Should Tereza “switch hats” and do the exam?

Example 2: Bayleigh is a doula, lactation consultant, and an essential oils distributor. Bayleigh’s client is eager for her labor to begin, and has a lot of logistical concerns about the timing. The client is just past her expected due date, so Bayleigh advises a protocol of essential oils to encourage labor to begin sooner rather than later. Bayleigh considers this recommendation to be something she does under her “essential oils distributor” hat, not her doula hat. Should Bayleigh have recommended the course of EOs that might induce her client’s labor?

Each of these examples include times when the doula would be stepping out of the doula scope by swapping an imaginary hat. Because these imaginary hats are a mental game only the doula plays, it can become confusing for the people the doula works with. Here are some possible outcomes from the mental gymnastics of hat switching:

Confused pregnant woman holding her belly

Tereza’s next client is a referral from the parents in the earlier example. This next client is planning a hospital birth with a CNM in attendance. Upon arrival at the hospital, the client refuses an exam from the nurse and says she wants Tereza to do it. Because Tereza did it for her friends, the client cannot understand why Tereza is uncomfortable with switching hats to provide her with the same services.

Bayleigh’s client does not go into labor as she had expected to after buying the oils from her doula and following the protocol to a T. She’s very disappointed and has lost faith in her body. At her next prenatal visit, her blood pressure is significantly higher than it had been, and liver function tests are ordered. She tells her OB that her doula recommended “a bunch of essential oils” and the OB believes this may have been a trigger for the issues the client is now dealing with. The client has now lost faith in her body and her doula, and the OB removes the doula from her list of recommended doulas, believing her to be improperly prescribing induction treatments.

These two examples are loosely based on real life scenarios I’ve seen play out in my local area. They are very real potential issues that could come from rationalizing stepping out of scope with the “switching hats” analogy.

My recommendation is to be clear *ahead of time* about your role. Have a contract that specified which role you’re being hired for (or which “hat” you are wearing) and stick with that throughout the experience with that client.

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