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In talking with my rabbi at the time I was beginning my doula practice, we agreed that there is halakhic grounds for a shomer-Shabbat woman to serve as a doula, provided that she not drive herself if another option is available (I pre-arranged with a cab company in case it became necessary to travel on Shabbat). The following is a summary of my research as presented to my rabbi.

Having recently received certification as a doula (professional childbirth assistant), I am urgently confronting the issue of whether I can serve as a doula on Shabbat. I would like to revisit the possibility that there may be sufficient halakhic grounds for me to be “on-call” as a doula on Shabbat in the same manner as a physician, midwife or other health professional. During our discussion a few months ago, prior to the beginning of my training, I had not yet researched the specific halakhic sources on this issue, nor did I adequately explain what a doula does. Since you mentioned that you would be willing to give the issue more thought, I would like to share my present thinking with you. Thank you in advance for reading this!

I will begin by providing background on the role of a doula. Next, I will turn to the potential halakhic justifications for serving as a doula on Shabbat. Finally, I will anticipate and respond to criticisms of serving as a doula on Shabbat.

I. What is a doula?

A doula, or professional childbirth assistant, is a woman employed by a pregnant woman and her partner to provide continuous psychological and physical support for the woman during labor, delivery and the immediate postpartum period. A doula works with a woman’s physician or midwife, using her expertise to help a woman focus and accomplish the hard work of labor. She provides emotional support, helping her client to acknowledge and overcome the psychological barriers that can cause labor to stall. She is a resource for the laboring woman’s physical comfort, e.g. she can help a woman find the most comfortable positions for labor and delivery, provide soothing massage, or assist with hydrotherapy. A doula is like a midwife without the medical background that a midwife possesses, and as such she can be a tremendous asset for a woman giving birth in a hospital setting, in which obstetricians and nurses are often too busy to provide continuous personal care. Like an obstetrician or midwife, a doula meets with her client before the birth and establishes a close relationship, built on the trust that when the woman goes into labor, she can count on her doula to be there for her labor and delivery.

A doula may join a couple at their home prior to the birth to assist the couple in laboring at home as long as possible, after which she will accompany them to the hospital; other couples may prefer to have their doula join them at the hospital. If a couple is planning a home birth, it is unusual for a doula to be involved, since midwives who do home births are likely to bring an assistant of their own; however, it could be that a doula would be present at a home birth, as well. In terms of Shabbat observance, potential violations would most likely occur in three areas: (1) using the telephone to respond to a call from a woman in labor, (2) driving to a woman’s home and/or the hospital, or (3) performing various tasks for the woman at home or in the hospital, such as drawing a warm bath or preparing a heating pad.

II. Halakhic Justifications for a Doula to Work on Shabbat

As we discussed, the major determinant of whether a certain type of work is acceptable on Shabbat is whether it falls within the category of pikuach nefesh. I believe that our sources provide a strong basis for a doula’s work of attending to the psychological and physical needs of a laboring woman to be considered pikuach nefesh.

The Mishnah (Shabbat 18:3) states that we may desecrate Shabbat on behalf of a laboring woman. The Gemara (Shabbat 128b) provides examples of what the Mishnah is referring to when it says, “we may desecrate Shabbat.” The Gemara brings a baraita that provides an example: the laboring woman’s haverah may kindle a lamp for her. Remarkably, the Gemara goes on to explain that this is true even if the laboring woman is blind! This halakhah is unambiguously repeated by Rambam (Hilchot Shabbat 2:11), the Tur (330), and the Shulchan Aruch (330). The Mishnah Berurah comments on the word soma: “Even though lighting a lamp is not basically meant as a cure, one may nevertheless do it for a laboring woman in desecration of Shabbat, since the Hachamim were convinced that a lack of peace of mind is a danger to the life of a laboring woman.”

In their wisdom, the Rabbis and later poskim recognized an important fact: perhaps more than in any other human circumstance, psychological and physical health are strongly linked during childbirth. Both psychological and physical factors shape the birth outcome. A woman’s “peace of mind” is just as vital as her physical strength and well-being, and every effort should be made to protect it.

Furthermore, as mentioned above, what matters is not that the laboring woman can actually see the candle, since the candle must be lit for her even if she is blind. What matters is her subjective need for the candle. We see this focus on the subjective need of the patient in other realms, as well. According to the Mishnah Berurah (330:4, note 14), Shabbat desecration is allowed when a woman who has given birth within the last seven days says she needs it, “even if a hundred doctors say that it is not necessary for her.” Likewise, Yoma 83a contains Rav Yannai’s opinion that if a sick patient says he needs food on Yom Kippur, we listen to the patient even if the physician says that the patient does not need food. In addition, when determining the halakhic criteria for termination of pregnancy, my understanding is that the psychological state of a woman is of significant concern. In all of the above cases, the underlying theme is “the heart knows its own bitterness” (Proverbs 14:10).

You mentioned in our last discussion that members of a woman’s immediate family might be permitted to drive to a hospital to be present for her labor, if she felt that their absence would be a barrier to her labor progressing normally. You were hesitant about whether a doula could be included in this circle of intimates who would be permitted to violate Shabbat in order to be with a laboring woman. However, if a woman felt adamantly that she needed her doula, with whom she has already developed a close relationship, or even if she felt that she needed a doula and had no relationship with a doula prior to her birth, I wonder how this is different than her (subjective) need for her husband (or mother, sister, etc.) to be present during her birth, or from the sick patient who (subjectively) needs to eat on Yom Kippur, and so on. It seems to me that the halakhic bottom line is that the needs of the mother, defined by the mother, are to be met.

A doula’s role and ability to be on call for her client can be as critical to her client’s psychological health as the ability of the woman’s obstetrician/midwife to be on call is critical to her physical health. In practice, a doula is properly understood to be an integral part of a laboring woman’s obstetrical care team. This is reflected by the growing numbers of hospitals hiring doulas and insurance companies reimbursing couples for the cost of hiring private doulas.

Even during and after a normal labor without complications, a laboring woman has the halakhic status of a choleh she yesh bo sakana. The presence of a doula can help prevent the life-threatening outcomes that are the origin of this classification. Clinical research by Klaus & Kennell (1992) has shown that the presence of a doula at a hospital birth reduces the incidence of Cesearean section by 50%, decreases the need for pain medication (which always poses a risk to the laboring woman and her baby) by 30%, shortens labor by 25%, decreases use of pitocin (synthetic hormone that brings on unusually forceful contractions at risk to mother and baby) by 40%, and decreases the use of forceps by 40%. Of course, it can be hard to predict whether or not a doula’s presence will prevent any “worst case scenario” for any given birth. However, some Shabbat-observant physicians, particularly during their residencies, are required to attend clinic on Shabbat and care for sick patients who are not yet in the category of choleh she yesh bo sakana – but who may successfully avoid life-threatening illness due to the care provided by the clinic physician. Kal v’homer, a Shabbat-observant doula should also be required to care for her client on Shabbat, since her client is already facing a life-threatening condition, and care by a doula has been proven to significantly improve obstetrical outcomes.

In addition, in the course of my doula training, I came to understand that the doula’s work is potentially life-saving at any time during a woman’s labor when the doula is the sole professional supporting the laboring woman. This is true even though the doula does not provide medical advice to the woman but instead guides her client in making her own medical decisions. This especially pertains when a woman plans to spend as much as possible of her labor at home and give birth at the hospital. A doula can play a critical role in saving the life of the yoledet and/or baby by expediting the yoledet’s decision to transfer to the hospital (e.g. if the woman’s water breaks and is filled with fetal waste, if she is experiencing excessive bleeding, etc.). In addition, having been trained in emergency childbirth procedures, the doula may actually “catch the baby” if it arrives precipitously, i.e. before the yoledet arrives at the hospital. At the same time, the doula’s role in pikuach nefesh can also manifest in the hospital. Obstetricians, midwives, and labor & delivery nurses employed by a hospital must oversee many patients simultaneously. Many obstetrical teams are grateful to see a laboring woman arrive at the hospital with a doula; they know that the laboring woman will be provided with continuous support and observation that she might not otherwise receive.

The sources are unanimous in their insistence on performing forbidden tasks on Shabbat with a shinui. The example given is that the haverah should tie a vessel of oil in her hair when carrying it to the laboring woman; modern-day techniques used by observant physicians include using an object rather than a finger to dial a phone number, or using the left hand to perform tasks that would normally be performed by the right hand. When caring for a laboring woman on Shabbat, one should always perform the action with a shinui unless performing the action with a shinui means that it “cannot be performed as briskly as it can be performed without the change in manner. [In this case,] it is a mitzvah to do it without making any change whatsoever, so that the matter will be attended to in the fastest way that is humanly possible” (Mishnah Berurah 330:1, note 5). In addition, the Mishnah Berurah explains that a woman in the ninth month of pregnancy should prepare as much as possible for a birth on Erev Shabbat (Mishnah Berurah 330:1, note 1). It follows that the same would be true with respect to the doula and other caregivers.

A number of criticisms might be raised as to why a doula should not be permitted to care for a laboring woman on Shabbat. Below, I will try to deal with each of the concerns that I have anticipated.

A. The role of the doula is not pikuach nefesh, the doula does not have a medical role, etc.

I have devoted considerable space to this issue above, so I will not belabor the point. I believe that ample justification exists in our sources for considering a doula’s work to be pikuach nefesh. Although she is not a medical professional, she absolutely plays a medical role. I will only add here that this critique implies that a doula is in a different category than the other “junior” members of a woman’s obstetrical care team, but there is no logical basis for this conclusion. It is taken for granted that actions taken to preserve the life and health of the laboring woman can be performed by Shabbat-observant medical personnel, including residents, medical students, and nurses – all of whom are overseen by more senior hospital staff. As an integral part of the obstetrical team that is caring for a woman in labor, it seems to me that a doula would have the same status vis a vis halakhah as any other member of the team who is subordinate to senior hospital staff.

B. The doula might be called prior to the onset of labor as understood by the halakhah.

The sources expend considerable effort distinguishing between different signposts that signal the onset of a woman’s halakhic status as a yoledet. It might seem that a doula would be at risk of violating Shabbat before her client has achieved the halakhic status of a yoledet, since a woman might call her at the earliest hints that labor is beginning. However, the Shulchan Aruch’s definition of the onset of labor allows for the onset to be determined if any one of the following has occurred: when she sits on the labor chair (presumably when she enters the pushing state, appx. 30 min. to 2 hours before the birth), from the moment that the blood starts flowing down (presumably the bloody show at the onset of early labor), or from the moment that her haverot need to carry her by her arms because she does not have the strength to walk (presumably the beginning of active labor). The Mishnah Berurah comments that “the ruling is different as regards calling a midwife from a distant locality or requirements of a similar nature, since the midwife would arrive too late if one waited until these stages before calling her. Consequently, it is permitted to call the midwife as soon as the laboring woman feels something, even if it is doubtful [whether or not labor has begun]” (330:3, note 9).

It is doubtful that a doula, then, would run into halakhic difficulty in terms of telephoning and/or driving to the woman before the woman was actually in labor. First of all, the bloody show is a signpost of early labor and is likely to happen before the woman calls her doula (the bloody show often acts as a trigger for a woman to call her doula). Even if a woman does not have a bloody show, she would have been counseled to wait to call the doula until she has difficulty walking during her contractions, as this is when a doula’s care becomes critical. However, the most compelling rationale is the Mishnah Berurah’s explanation that the midwife can be called if the woman “feels something,” even if there is doubt about what she feels, since it is important that caregivers arrived on the scene before it is too late. For reasons enumerated above, no distinction should be made between a midwife, doctor or doula (or any other person whose presence will impact on the psychological and/or physical well-being of the mother).

The Shulchan Aruch rules stringently against delivering the child of a non-Jewish woman on Shabbat. In the name of the Magen Avraham, the Mishnah Berurah allows one to deliver the child of a non-Jewish woman on Shabbat if refusing to do so may lead to animosity. The Mishnah Berurah then harshly condemns doctors who treat non-Jews on Shabbat, calling them “not careful” (330:2, note 8).

A full discussion of medical treatment of non-Jews on Shabbat is far beyond the scope of this paper. However, my understanding is that it is no longer permissible to make distinctions between Jews and non-Jews in terms of saving a life on Shabbat. My understanding of this halakhah is based on conversations with shomer Shabbat doctors as well as discussions of this issue when the first perek of Mishnah Yoma (in particular, the issue of rescuing people trapped under a mapolet on Shabbat) at Pardes. My own strong feeling on this is that we are all created b’tzelem elokim and to deny care for someone on this basis is a devastating hillul Hashem.

In summary, an increasing number of women are choosing to have doulas attend their births as the statistics proving the benefits of doula care continue to receive more publicity and accolades. When we first discussed the possibility of me serving as a doula, I believe I mischaracterized it as a purely non-medical role. Halakhah seems to reflect the belief that the laboring woman’s psychological state is of utmost importance in preventing the death of mother and baby, and we can infer that guarding the psychological health of a laboring woman is tantamount to saving her life. In a sense, by providing psychological support and physical comfort measures which facilitate the progression of labor, the doula plays a critical medical role. Furthermore, even if we do categorize the doula as “non-medical,” the mention in halakhic sources of the haverah indicates that halakhic authorities assumed that “non-medical” persons would be present at a birth and could conceivably be asked by the laboring woman to perform tasks that would violate Shabbat. Finally, a doula may actually play a role similar to a midwife or physician, whether or not this is intended, at times when she is the sole professional supporting the laboring woman.

I deeply believe that my will and ability to be shomeret Shabbat and to be on-call to help laboring women as a doula are not incompatible.

Note 1: Obviously, we are not talking about Shabbat desecration in the abstract! The example used in the Mishnah Brurah is the preparation of hot food.

Note 2: Maternal mortality increases four-fold with a cesarean birth, from 1/10,000 for all vaginal births (.5/10,000) with normal vaginal births to 4/10,000 for cesarean births. (Source: International Cesarean Awareness Network). Babies born by cesarean section are more likely to have difficulty breathing because they do not receive the stimulation of going through the birth canal. Immediate bonding between mother and infant is not permitted after a cesarean birth, with detrimental effects to both mother and baby (Sears, Dr. William, The Birth Book, 1994).

Note 3: The delivery is allowed, but only “as long as the tasks performed do not entail Shabbat desecration.” Yet it is hard to envision a birth scenario that would not involved Shabbat desecration of any kind, and yet would preserve the life and health of the mother, given our current medical practices of cutting the umbilical cord, suturing tears in the woman’s perineum, etc.