What's different about being a doula outside of the hospital?

When I posted about attending my first home birth, one commenter asked:

"As a doula did you feel that your role was very different? I had both of my children at home; looking back I wish I had a doula. My midwives, are amazing but they are very hands off and quiet. I think a little more direct verbal support could have greatly shortened both of my labors."

I have been thinking about my response to that comment since attending another out-of-hospital birth and another hospital birth since then. Below are some thoughts, some of which were included in my reply to the original comment:

It has been most interesting to experience the feeling of having to do zero "defense", to not even have to prepare myself for the possibility of running interference. When all of a sudden I no longer had to have my guard up, I realized how much energy and attention I was spending on it. I didn't have to tense myself to find out if the next nurse or OB or midwife on shift was friendly or hostile, flexible or rules-obsessed. I didn't have to explain any birth plans to nurses or nag anyone to get the monitors off or try to soften the impact of discouraging words. I didn't have to help navigate decisions where the woman couldn't be sure whether she should trust her caregivers' recommendation. And in terms of my role, I knew I was totally welcomed and my role was perfectly understood by the midwives there. It was amazing just to toss all that defense aside, know that both the families and I were in a place they could trust, and be 100% focused on labor support.

I also felt very confident that I could let the midwives take over the role of suggesting position changes, etc. when they were around - that was a new feeling. Sometimes in the hospital, I feel like I am the only one taking responsibility for suggesting proactive things to progress labor, ensure optimal fetal positioning, etc., and again I am always on guard that those will be met with negative feedback by the nurses ("what's she doing on the TOILET?") or resistance by the mom ("do I have to move??") Outside of the hospital, the midwives were on top of that stuff, and they had the trust and authority to say "It's really important and I think it would help you, let's get you walking again". I sometimes suggested things as well if I sensed it was the right moment, but I never worried that I would be the only one or that the midwives would be reluctant to try anything the mom was up for.

So I would say the main difference has been in feeling real trust and confidence in the caregivers - that they were on exactly the same page as the family, that they had and used skills that I consider very important, and that everyone who would be there throughout the labor and birth would share those goals and skills.

While one of the reasons I encourage everyone to have a doula for a hospital birth - that guard/buffer role - was not necessary for the out-of-hospital births, I look back and think how much that freed me up to simply focus on the woman and fulfill all the other parts of my doula role. I think a helpful role that I played was in being there before it was time for the midwives to arrive: encouraging rest, suggesting position changes, giving feedback on where I thought labor was at, helping get the tub set up, etc. Many people are ready for some trained labor support before they're really ready to call the midwives. And after they got there I was still doing verbal support/encouragement, taking turns doing counterpressure, and of course the "gofer" role that doulas do so well. And like the commenter mentioned, sometimes your midwives give you wonderful care but their labor support is just not the kind that helps you the most. I would encourage anyone to have a doula at a home birth!