Extortionate fees or extreme value for money?

Posted by: on Feb 8, 2018 | No Comments

If you think doulas are expensive, trust me, you are about to find out just what good value we actually are.

This as an open letter to Dr Ahmed Rashid, an NHS doctor, in response to his comments about doulas in the British Journal of General Practise, February 2018….

” I first came across a doula as a junior doctor working in obstetrics and the idea has fascinated me since. In case you haven’t heard of them, they are trained or experienced lay women who provide social, emotional, and practical support during pregnancy and birth, but do not provide any clinical care. Although the practice has ancient origins, the modern doula movement began in the US in the 1970s and private doulas, hired by mothers (often for extortionate prices), have been popular in certain parts of the UK for some time. A recent Oxford study focused instead on volunteer doulas, trained by third-sector organisations. After interviewing 19 doulas and 16 mothers who had received their support, the authors concluded that they can play an important role in improving women’s birth experiences by offering continuous, empowering, female-focused support that complements the role of midwives, particularly where the mothers are disadvantaged. Perhaps it’s not such a bad idea after all.”

Dear Dr. Rashid,

I’m not sure you appreciate quite how much work goes into doulaing, and the costs we incur in the act of doing this valued work, so please allow me to enlighten you.

Firstly, training to become a doula is not an undertaking which is funded by an employer but is paid for by the woman herself. During her initial training a doula will likely spend hundreds on the training course, and hundreds more on books to better understand the many complex needs of the women they serve. Some clients will have experienced earlier birth trauma, others may be survivors of childhood abuse or domestic violence. Even straightforward births can be greatly assisted by a doula who is skilled in certain things – which in themselves may also cost money for her to learn or do. Aromatherapy oils are not provided for free to doulas, nor are such things as a rebozo scarf (extremely useful tool which I invite you to google), or the many other items doulas might carry in their bag to aid women to give birth. The NHS budget doesn’t always stretch to some things which are proven to help women and which doulas invest in as part of their toolkit.

Furthermore, doulas take pride in continuing to learn after their initial training, and supporting women may take on many forms – providing assistance with all manner of skills which don’t happen by magic but are gained through training courses, which also cost money to attend – when you consider course fees, travel costs, accommodation costs are all out of the pocket of the doula herself, this adds up.

Then there are yearly insurance fees, membership to Doula UK, taxes, fuel costs, hospital car park fees, website/ promotional / advertisement costs, mail system fees, payment fees (paypal costs for example). We don’t get new clients by pure magic. And even word of mouth can only go so far.

Consider this – a doula is potentially putting aside a whole month of her life during every ‘on call period’ with a caveat on all commitments or social arrangements that she makes to ensure that she can reliably attend the birth of her client who has invested a lot in her emotionally besides the financial cost of hiring her. If a doula charged £1,000 per birth and booked 12 clients a year, forgoing a holiday, that is a maximum yearly income of £12k, before taxes. This is hardly extortion, when viewed in this light.

I conducted a poll this very evening on a Doula UK forum to see what the average doula charges for doing all this work. There were 30 respondants, with the mean average fee for births, including London pricing, coming in at £787.

Does this in all honesty strike you as moneygrabbing, or extortionate, Dr Rashid? Could you or would you, do this kind of work for that sum? Would you put your whole life on hold for that? Even those women who charged at the upper end of the scale gave detailed descriptions of the numerous antenatal and postnatal visits included in their package with a broad range of services to assist mothers in recovery from childbirth – none of which are even remotely available on the NHS.

Going to births can be gruelling. It is a sweaty, bloody, pooey, pissing, puking, very much hands-on kind of job. I have come away after 27 hours solidly supporting a woman and her partner absolutely drained to my core. Unable to drive myself home safely. Emotional. Aching all over. Bruised. I have known doulas to stay with women for five days straight. This job is not for the faint-hearted! Plus, who do imagine looks after our children while we do this work? And at what cost?

Please do not underestimate how much this job takes out of us. You may think we just massage our clients back a little for a few short hours and squeeze their hand whispering encouraging things but you do not see the hours of invisible work, research and worryinwe do for our clients. This is more than hand-holding – we support women’s journeys with our whole being.

You may not know of the meetings or email exchanges for the months before, providing information and signposting towards services and resources, or the messaging at 1am trying to resolve breastfeeding issues as a mother struggles and needs someone to talk to who has been there and can help…. but we do. It’s a normal part of our work.

The Cochrane review has already demonstrated our influence in the birth room as a force for good, and I can vouch for this in my own experience. The mothers I support talk about how transformational the process of becoming a mother has been for them, and have often told me how integral my support has been in facilitating the family’s bonding, healing, recovery, and initiation into parenthood. I have had fathers message me, thanking me and saying how much my influence has shaped their partners identity as a new mother or helped shape their parenting journey per se. I also know, from my work as founder of the Birthplace Matters campaign, that relying solely on the care of the NHS alone can leave some women utterly high and dry – the stories I have been told are freely available on http://www.birthplacematters.org.uk if you care to see what standardised care without doula support looked like for some women. The NHS is severely stretched and midwives cannot always offer the care they would wish to – this is where doula support is especially valuable.

Would you really have us all offer this dedicated extended support spanning many months either for free (which doulas do sometimes offer for a valued friend or for access fund clients (where a few basic expenses are funded through a charity but they receive no other payment at all for the birth or on call period) or for a measly couple of hundred pounds?

I respectfully ask you to reconsider your comments about our true value in the light of the many ways that doulas help women and their families. We do this work for love, not to get rich.


I hope you perhaps appreciate now how much we doulas are in fact excellent value for money!
Paula Cleary
Doula and Founder of Birthplace Matters