In the UK, most people access pregnancy, birth and postnatal care through the NHS. However, an increasing number of people are now choosing to look outside the NHS and to employ someone directly. Once you start exploring options it can get very confusing. What exactly are midwives, doulas and birthkeepers?

In this blog post I aim to explain a little about the options and the differences between midwives, doulas and birthkeepers and some thoughts about how you might choose who you want with you at birth..

Midwives, doulas and birthkeepers are all readily found through social media. Some people will also opt for private care from an obstetrician (a doctor specialising in pregnancy and birth).

In the UK, midwives are very closely regulated by the Nursing and Midwifery council (NMC). This is our registering body, which defines the necessary education and the standards and scope of practice of a midwife. In order to practise as a midwife in the UK (or to use the title), we have to have completed an approved educational programme (degree level) and to maintain our skills and competence. The title “midwife” is protected, meaning that it is illegal for someone to use the title unless they are currently registered as a practicing midwife. Midwives are recognised in UK law to be the experts in normal pregnancy and birth, and our professional standards require us to seek medical input if any features of concern arise. The registration and updating requirements are the same for midwives working in the NHS and those working privately.

Midwifery is a “protected function” in the UK, meaning it is a criminal offence for any one other than a registered midwife (or a registered medical practitioner) to “attend on a woman in childbirth”. That does not mean that you cannot give birth without a midwife or doctor present, but it does limit what anyone else can do to monitor or help you. The organisation Birthrights provides very useful information about what they describe as unassisted births. Some people choose unassisted or free birth because they do not feel comfortable with the medicalisation of birth or of being told what to do, or are fearful of hospitals. I talk with many people who have had difficult or traumatic experiences in the past or who are deeply concerned by media reports of problems in the NHS. Whilst I absolutely understand and respect these concerns, I know that high quality midwifery care can be life saving or life changing in some situations. The challenge is to get the good aspects of professional care without the bad.

As a private midwife, I am able to offer a very personalised service, tailored to your particular situation and respecting your preferences and beliefs. I believe that in most cases, pregnancy and birth are normal events which require little intervention from me. Much of my role is checking that things are progressing normally for the birthing person and the baby. Checks such as blood pressure, urine tests and baby’s heartbeat can give reassurance, but can also warn of potentially serious problems which can be averted or managed using 21st century medicine.

I believe that nature works very well most of the time. I also know that nature isn’t kind. Sometimes things go horribly wrong and swift interventions are needed. My job is to identify signs that things are not going well and to know what to do next. I love attending births when everything is very straightforward, but I am always poised and ready in case things change. I love the analogy which I heard some years ago. A midwife is like a cat sitting on a roof in the sunshine, observing. They may look as if they are doing nothing, but if something catches their eye they are instantly alert and ready to act.

Not all of midwifery is about birth. The professional remit of a midwife covers to whole of childbearing, from preconception care, through pregnancy, birth and the first few weeks of life.

I work with some wonderful doulas. Doula UK provide a useful explanation of the role of doulas. The title of doula is not a protected title and there is no standardised educational programme. This means that you need to make careful enquiries to ensure that you understand their skills base and interests. Their role is supportive, both in emotional and practical issues. Some specialise in preparation for birth (including antenatal education and hypnobirthing training) supporting parents during labour and birth, or supporting new parents in the early days with their baby. Others offer shamanic rituals or alternative therapies.

If you are having a hospital birth an experienced birth doula who is comfortable in the hospital setting can be extremely useful. If you undertake preparation with them they can support you to use tools such as hypnobirthing or massage, be a familiar voice in the unfamiliar setting and advocate for you. At a homebirth with a midwife they can support you practically and emotionally in many ways. Some doulas attend to provide support and guidance during free births. Whilst many doulas are hugely experienced and skilled it must be remembered that they have not had the same education as midwives and are not able to undertake any physical assessments or interventions. Occasionally I have met with doulas who are so strong in their support of normal birth that they advise clients to “just say no” to any interventions or examinations and who strongly encourage freebirth. I was banned from a doula controlled Facebook group a while ago when I had the audacity to comment on a post which I felt was encouraging a very risky situation. I feel it is too easy to encourage freebirth from a position where you are not going to be there or to have to deal with the aftermath if things don’t go well.

As a midwife I have witnessed, and had to act fast, in situations where normal became life threatening very suddenly. If all goes well, maybe you didn’t need a midwife, but it isn’t possible to know in advance which births are going to go entirely smoothly. I am delighted to work collaboratively with doulas who are happy to work collaboratively with me.

Birthkeeper is a term which has recently become more common in the UK. In the US where pregnancy and birth are in most cases managed by doctors, birthkeepers offer normality-focussed support. It often has a strong spiritual philosophy. A description of one interpretation of the role is here, but the title is used by many people with a wide range of knowledge and experience. In the UK, there are a number of people who once qualified as midwives but have not maintained their professional registration, who are using the description. Some of these birthkeepers have extensive experience as midwives but currently unable to get insurance to attend births as a midwife. There is information about that challenge in my blog post Private midwives, independent midwives and insurance. It is important to remember that someone who has been a midwife but who has not maintained their registration cannot legally provide any midwifery care (monitoring, examinations, interventions etc). However, anyone can call themselves a birthkeeper.

So what is the difference between midwives, doulas and birthkeepers? All offer preparation for birth and attendance at the time of birth. The difference is in the skills and knowledge and the ability to act when things get complicated. With a doula or a birthkeeper, you are freebirthing. If you are worried about things you have heard about birth or have had a previous traumatic experience I am always happy to offer a free short consultation to explore your concerns. I believe that birth with a respectful midwife offers the safest situation.

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