Diaper dolls from a birthing class
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Illustration by Xiaohong Zhang

Nikki Helms was elated when she received word that she’d been accepted into the Sharp Mary Birch doula program. A doula since 2003 and currently also a student midwife, she believed the hospital’s endorsement could put her in a favorable position to bring in a steady client base for her doula practice.

“My personal excitement was about the privilege of being in this very small, select group of women who have been trained and interviewed to be associated with this hospital,” she says.

But in the hospital’s eight-hour training course for doulas who’d been accepted into the program, what she heard “made me question my ability to practice,” she says.

We’re sitting in the comfy, cushiony waiting area at the Birth Education Center of San Diego in Mira Mesa. Photographs of happy pregnant women, newborn babies, and dewy-eyed fathers adorn the surfaces around the small room. The door to an adjacent classroom stands open revealing large pillows in place of traditional classroom seating. Depending on the day, the pillow room fills with women learning everything from hypnobirthing to breast feeding to “belly dancing for labor.”

This morning, the Center is dim and quiet. Its founder, Care Messer, has been held up elsewhere and is unable to join us in person. Earlier, Helms expressed discomfort in holding this meeting without Messer, an outspoken doula and hypnobirthing instructor whose name comes up often in the San Diego natural birth community. So Messer joins us via speakerphone.

Nikki Helms

Nikki Helms

To understand Helms’s story, it’s important to understand what a doula is. According to DONA International (formerly Doulas of North America), the largest nonprofit organization that trains and certifies doulas, “doula” refers to “a trained and experienced professional who provides continuous physical, emotional, and informational support to the mother before, during, and just after birth; or who provides emotional and practical support during the postpartum period.”

DONA says a birth doula’s job includes staying with the woman during labor; providing “emotional support, physical comfort measures, and an objective viewpoint, as well as helping the woman get the information she needs to make informed decisions”; and facilitating communication between the laboring woman, her partner, and her clinical care providers.

“It’s really important that you have someone that’s able to put that time in with you. You want to have that intimate relationship with someone who is going to be there with you continually,” Helms says. “The same is true for hospitals as it is for birth centers. You may see the same midwife in the course of your care, but on the day you go into labor, if she’s not on call, then you don’t have that continuity of care. They’re going to give you good care regardless, but your doula is there next to you the whole time.”

A DONA birth doula certification requires a 16-hour workshop every four years, in addition to extensive reading and resource development work. “The number of hours a doula can put into her initial certification can vary on how busy the doula is,” Helms says. “There are essays to write, books to read, and if she’s a doula with young children she can find herself up against their DONA-stated four-year time limit pretty quickly.”

Doulas can practice in three different ways: as private hires, as hospital or birth center volunteers, or as hospital employees. University of California San Diego Health System offers the Hearts and Hands doula program, and Best Start.

“There are several places that offer volunteer doulas [in San Diego]. UCSD has a volunteer doula program, and they’re fantastic. The doulas that are there, most of them work in the birth center, but they will come to you if you’re on the labor and delivery floor,” Helms says.

Best Start Birth Center provides a volunteer doula for women who can catch one on-call during the labor process, but they also have a low-cost doula referral program for those who want to hire a doula earlier in the pregnancy. All are DONA-certified.

Most for-hire doulas work with women in home birth, birth center, and hospital settings. Occasionally, friction occurs between doulas and nurses and doctors in hospitals, Messer and Helms say. But they agree that the more familiar everyone becomes with each other’s role the less friction arises.

“I’ve worked with families in hospitals and in birth centers and in home births,” Helms says. “Sharp Mary Birch has been the one hospital that has made it more difficult. Other hospitals, other establishments have made it easier for doulas to be a part of the birth team.”

But even knowing this, Helms applied for and interviewed for a position on the hospital’s now-18-month-old doula program. “I went into the program in the hopes in the back of my mind that I would be able to help women and affect change and be a strong advocate for natural birth, because I believe we were made to do that,” she says.

She interviewed and then waited weeks to hear back. When she was chosen to be one of the nine doulas currently on Mary Birch’s website, she was thrilled.

Until she sat through the training. “As I’m listening during the course of the day, I’m hearing all these things about how women are not being empowered to labor and deliver under their own power. I’m realizing that as much work as they’ve done to be baby friendly, they’re not actually Mama friendly.”

Care Messer

Care Messer

Messer suggests that the Sharp Mary Birch doula program is little more than a smart marketing ploy. Their website makes it a point to emphasize that their doulas are DONA-certified and that “doula-supported labors result in reduced use of intravenous pain medication and a decreased need for epidurals.”

“I think what Sharp thinks is if they have a doula program, it will attract so many moms that will hire their doulas,” Messer says. “It’s good PR for them.”

Below the surface, however, the two say the program strips away a doula’s ability to do her job the way she’s been trained to do it. Messer says one doula texted her during the training and summed up the program for her. “They basically said, ‘You’re supposed to help the nurse. If the nurse says get an epidural, get an epidural.’”

The DONA code of ethics reads, “The doula’s primary responsibility is to her clients,” and both Messer and Helms believe that this goes against the policies and procedures at Mary Birch.

Messer teaches a class at the Birth Education Center of San Diego in Mira Mesa

Messer teaches a class at the Birth Education Center of San Diego in Mira Mesa

On one hand, the hospital has the right to expect its employees to conform to policies, procedures, and staff hierarchies. But doulas in their program are actually paid by the parents. Their website makes this clear, “The $900 fee for doula services will be billed directly to you and is not typically covered by insurance.”

Helms has no problem with the referral system, but she does believe expectant mothers who sign on with the Mary Birch doula program are not getting what they’re paying for. “You as the customer/client are not getting the full benefit of training and experience of the person you’re hiring because they’re being sequestered by that particular hospital system,” Helms says.

“That’s the rub of it. They’re paid as an independent contractor by the patient, but as an employee, they can’t give them all the information,” Messer explains. “If the nurse says you have to have an epidural, then that’s what we’re going with. If I’m working for them [as a doula in their program], and I say, ‘Hey Mom, do you guys want to think about that for a second?’ and they say, ‘Yes,’ and I stay in the room and they choose not to get an epidural, then who’s going to get fired? Me, because I suggested that there were other alternatives.”

Messer cites intermittent (versus hospital-favored constant) monitoring as well as eating and drinking during labor among the choices a doula can offer from outside the Mary Birch program that could get her fired if she signs on with them. “[Leaving the program] would open up all these options of things [a doula] could say and empower the mom with, [which] she couldn’t have done 15 minutes before when she was an employee,” Messer says, “even though [as an employee] she was paid by this mom the whole time.”

Mary Birch responded through its public relations department, which wrote, “Patient feedback on our doula program has been overwhelmingly positive.”

Regarding the question of allowing women in labor to eat, Mary Birch stated, “We ask that laboring moms avoid eating and drinking as this presents a safety issue during emergent situations.”

The question Messer believes Moms should ask about doulas in the Mary Birch program is, “Are they going to advocate for me, or are they going to follow the rules of the hospital?”

Messer says she has had good experiences working with mothers at Mary Birch as an outside doula. “I’ve had very good births at Mary Birch. But as a doula, I go in very mellow. I get my parents in there at the very end, and we work with the staff, not against the staff,” she says. “I think there are some rogue doulas out there who think they’re God. They go in thinking, ‘I have to take on the hospital for this mom,’ and that’s not what the doulas are supposed to do.”

The Mary Birch website explains that while outside doulas are “welcome,” one benefit to choosing one of their doulas is that, “This program helps to take the work out of researching, interviewing, and hiring qualified doulas and acquainting them with hospital staff and procedures.” Messer claims that this message merely pays lip service to the idea of providing options to families. When her clients plan to give birth at Mary Birch, Messer works with them at home for as long possible before going into the hospital. “The doula’s role is continual support,” she says. “My job is to keep him fed, them both going to the bathroom and eating, whatever. As soon as we get to the front desk at Mary Birch, security guard says, ‘Mom plus one.’ Mom now has to pick between her doula who is helping support her through this whole process or her partner.”

Her voice rises with indignation that’s evident through the speakerphone in Helms’s hand. “Well, dad’s not going to miss the birth. So now they’ve separated us,” she says. “But if they’ve hired a Mary Birch doula, they’re an employee. They can come right up with you, and you can have continual support the whole time. So the message is, ‘If you don’t hire one of our doulas, you’re not going to have the support that you need to have a beautiful birth.’” But even the privilege of having access to her clients through the triage process is not enough to make Messer want to sign on with Mary Birch’s doula program.

Why not?

“Because it limits the parents’ options,” she says.

Beyond the privilege of having access to clients through the triage process, why would a doula want to sign on for their program?

“Money,” says Messer. “Money, because some doulas have a hard time getting regular clients, and if the hospital is [promoting] you out to ready-made people right there who are considering a doula, you’re going to get $800 right off the bat. Even in regular practice if you haven’t done many births, you might get $400 or $500 until you build up your experience, but now you’re going to get $800.”

Messer also says some doulas sign on hoping to elicit change. “[Some doulas think] ‘If I get into the hospital, I can start making changes for doulas everywhere,’” she says, “But then once they got into the training, it’s like, ‘Wow, I can’t labor with them at home. Wow, I can’t give them options that they can eat and move around. I can’t let them know that they can have intermittent monitoring.’”

Helms teaches a class at the Birth Education Center of San Diego in Mira Mesa

Helms teaches a class at the Birth Education Center of San Diego in Mira Mesa

Helms admits that she thought she could change things from the inside. But once she saw what she was up against, she decided she would be better off using her energy elsewhere.

“I tried to figure out if I should suck it up and push through, because I really wanted to try and help these women,” she says. But she decided it was “going to be a continual fight against the system. And how much will that take out of me as a person, and how much will that affect how I practice? So, I said, ‘It’s been lovely. Thanks very much. I gotta go.’”

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krijnr Aug. 6, 2015 @ 2:04 p.m.

As a new parent who actually used the program, I can say this article could not sound further removed from the reality of my experience. There is no way the security guard made anyone choose between the dad or the doula. We had 5 people in the room throughout the delivery, and during orientation Mary birch makes it very clear you can bring as many people as you like. Our doula, whom we hired through the program, advocated for us alone throughout the naturla birth (no epidural for my brave wife!). It sounds to me like the author and people quoted have some beef with Mary birch or something. Sad, because now fewer people will actually end up using a doula at Mary birch. I expect some more balanced reporting from San Diego s last remaining real paper...


Bee858 Oct. 19, 2015 @ 3:19 p.m.

I think they are referring to the triage room. If I remember correctly from my tour it's the room where they get you all checked in. (It might be on the first floor) This is where they only allow the mother and one other person. You are correct about as many people as you would like in the recovery room.


TamaraLL Aug. 7, 2015 @ 2:02 a.m.

So much incorrect information in this article. Was any real effort made to follow up on these claims? Nurses don't tell moms they "have" to get an epidural. Does a doula tell a mom that she can't get one? It seems from the doula's words that she is only interested in helping moms achieve a "natural" birth. Is she referring to natural as in vaginal or no medication?There are families that hire doulas and still want to have medication used.

It's not the doulas job to tell moms to eat during their labor. Although the risk of general anesthesia being used is extremely rare, this is followed by most hospitals and not job of the doula to tell a mom to eat no matter which hospital she is delivering at.

Did this doula even attend to any births through this program? It doesn't sound like it. She is making all these assumptions from what she thinks she heard at the orientation. Intermittent monitoring is a possibility depending on the choices a patient makes. Why is there a shower and a birth ball in the room if the patient is immobile as stated in the article? Are those just for show? Doulas are a fantastic addition to the labor process but families need to also advocate for themselves with their health care providers in advance of having their baby and empower mom and partner.


CatherineRN Aug. 7, 2015 @ 12:52 p.m.

I have been a Labor and Delivery nurse for 25 years and I have NEVER told a patient they had to get an epidural. I have encouraged it as an option for pain control when my patient has exhausted all of her own coping skills. NONE of our anesthesiologist will perform an epidural on a woman who does not give verbal or written consent. While you clearly are a proponent for an unmedicated birth, I cannot remember a time where a woman said "Take the epidural out, I'd like to feel that pain again." While I consider myself to be one of the best at helping a woman have an unmedicated birth, I also just want my patient's to have a safe delivery with a healthy baby. As for separating doulas and fathers.... We currently have NO visitor restrictions at Mary Birch, I know of no doulas who have been turned away. As for eating and drinking in labor, a large percentage of our patients desire an epidural, anesthesia is a risk, so to decrease the risk of complications, our patients may not eat solid food. This article is ridiculous and only serves to further incite animosity between health care professionals and the community we serve. I personally love having doulas with my patients because it tends to go with a patient who has educated herself on the labor process, more than "reading an article on the internet, watching a video on youtube, or consulting Dr. Google and Dr. Wikepedia." I think that currently, less than 25% of our patients do any type of childbirth education. While we all have freedom of speech, articles like this do more harm than good. Now maybe you could do a survey of how many women had a great birth experience at Mary Birch, with or without an epidural.


Bee858 Oct. 19, 2015 @ 3:23 p.m.

I think they are referring to the triage room where they only allow the mother and one other person. During my tour I was told just two of us in triage. That means picking a Douala or my husband.


knb Aug. 7, 2015 @ 4:28 p.m.

I am glad this article was written. I have recently heard some not so great things about Mary Birch and am glad I delivered at Scripps. At least this article will force people to become educated either way. I agree that it is a slippery slope to have a person that is supposed to be YOUR advocate to an institution, employed by that institution. I do not see how they can remain unbiased that way. I still believe word of mouth and the website http://beautifulbeginnings.org/ are the best way to find a doula. I found Ali Feroah this way and she is/was AWESOME!


greader23 Aug. 9, 2015 @ 8:55 a.m.

I am appalled at the amount of incorrect information in this article. This is completely one-sided and would have been more balanced if the writer had done some fact checking and strayed away from passing opinions as facts.

I've worked at Mary Birch for over 5 years now and have held three different positions. I can tell you now that the claim of having to choose between the mother's partner and the doula is misleading. That only occurs in triage where the nurses are assessing if the patient is in active labor. Once the mother goes up to L&D then she may have as many people in the room as she wants. The triage area is a small space, and at Mary Birch there is an average of 30 babies born a day, imagine trying to fit the mom and dad, their doula, and their family in the small space when she's being assessed in triage. It doesn't work. It's not a non-doula policy, it's a safety/fire code issue.

For Messer to say that an opinion texted to her from the doula in the Mary Birch training program is a "summary" of the program is ridiculous. To say that RNs force the epidural is just plain wrong, and there is no evidence to support their claim. I can tell you that I code of epidurals in my job and I have seen many patients who choose to go without an epidural. Although, I also see many women who end up having a 3rd/4th perineal degree tear (tearing through the vagina to the anus), and I highly doubt that they regretted getting an epidural.

I find it interesting that Messer claims that as a Mary Birch doula she would get fired if her patient decides to forgo the epidural (which is again her opinion, not fact). My question to her would be, who do you think is ultimately responsible if that same mother was unable to progress during labor and the baby ends up in NICU....or worse, as a fetal demise? Or what about all the mothers who are sent to Mary Birch from Best Start and other natural birthing centers when complications occur?

This makes me angry because these two woman and the author are distracting from the amazing work the Mary Birch doctors and nurses do everyday. This unbalanced article is slander in my opinion. San Diego is extremely fortunate to have a women's hospital that specializes in high-risk pregnancies.


Kellie May 11, 2016 @ 12:41 a.m.

I have always loved going to Mary Birch and also Children's Hospital. The staff is always friendly, helpful and supportive. As a doula in San Diego myself I am always supportive of my client, but understand that there are times when I must step back and let the doctors and nurses do their job. In most cases we are both looking out for the best interest of the mother and the baby.

My experiences with Mary Birch have always been positive. This article presents the experience of one person.


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