New Life Midwifery Doula Agreement
Kelley Faulkner, DEM
508-429-MOM3
http://www.newlifemidwifery.com
Dear Parents,
Congratulations on your pregnancy and thank you for your interest in professional birth support! Many families are realizing that this "peak" life experience can also be an overwhelming time, especially with all the choices to make regarding the health care of mother and baby. The vast majorities of families that have used a doula have found that a doula’s presence at the birth and in their home can mean the difference between a satisfying, empowering experience versus a fearful and sometimes traumatic event.
Numerous studies have shown the following effects of doula support:
· Births are shorter, likely due to less use of intervention.
· There are fewer, if any, complications.
· Cesarean rates are drastically reduced.
· There is rarely a need for oxytocin to speed up birth.
· Use of forceps is extremely minimal.
· Women request less, and more often no, pain medication.
· Mothers have less incidences of postpartum depression.
· Babies have shorter hospital stays and fewer admissions to special care nurseries and have higher success with breastfeeding.
Enclosed is some general information about our services for you to review and discuss. This agreement outlines our responsibilities as doulas, your responsibilities after hiring us, and how we work together cooperatively. The payment structure is also defined. If you have any questions about anything in this packet, or if you would like to set up an appointment for an interview, please call 508-429-MOM3. We look forward to helping you realize your birth and parenting dreams!
Sincerely,
New Life Doula
Agreement for Birthing Support Services
Your Doula’s Goals
§ To support you during your pregnancy, birth & postpartum period, in whatever choices you make.
§ To believe that birth is a normal physiological process and a sacred journey in a mother's life.
§ To provide information so you can make informed choices and remain current on birth research.
§ To maintain complete confidentiality of all details relating to your pregnancy and birth.
§ To support you in having a positive birth experience and achieve the type of birth you desire.
§ To provide reassurance and perspective, offering ideas to help birthing progress, and help with relaxation, massage, positioning, and other comfort techniques.
§ To provide physical, emotional and educational support. If you wish for more clinical care during birthing while you are at home, you may hire us as Monitrices. Doing so means that we may also perform clinical tasks with your permission such as blood pressure, exams, and fetal heart rate monitoring in your home to help you stay at home longer and with more confidence.
q Please check this box and initial if you are hiring us a your Monitrice. ______
Our Obligations as Your Doulas
§ We will be on call and available for you 24 hours a day beginning three (3) weeks before the estimated due date (EDD) and up until birthing begins.
§ The doula named will take responsibility as your primary doula. If for any reason you are unable to contact her within 20 mins when birthing, please call your designated back-up doula.
§ We will meet twice prenatally to discuss the role of a doula, talk about your expectations, answer your questions, discuss birth plan options, when to call us, etc. Additional visits are available.
§ We will assist in drafting birth wishes and offer consultation by phone before birthing begins.
§ We will provide early birthing support in your home, remaining with you until 1-2 hours after birth.
§ We may utilize non-interventive support techniques for birthing, including homeopathy.
§ We will provide emotional support by telephone prenatally and postpartum care, as requested.
§ We will help to initiate the breastfeeding process, as needed.
§ We will meet within one month postpartum to answer any questions, offer professional referrals, and reflect on the birth. Additional follow-up visits can be arranged.
§ If a cesarean section must be scheduled, we will still be present to support you.
§ A copy of all your confidential records will be given to you, upon request.
Your Obligations
§ You must arrange for attendance (midwife or doctor) at your birth.
§ If you plan to have an “unattended/unassisted birth” you must inform us prior to birthing.
§ You will create birth wishes and discuss these with your care provider, ensuring that your care provider and the staff at the facility you are birthing in agrees and supports your wishes.
§ You should provide honest answers and information about your history and your birth intentions.
§ You will call your doula at the earliest possible point when you think you may be beginning to birth, even if you are not sure, so that she may make arrangements to attend your birth.
§ You will allow us approximately one to three hours to reach you.
§ You should maintain your own excellent health and nutrition.
§ You make all decisions regarding your care and when to call your provider or go to the hospital.
§ If you decide not to use a New Life doula after signing this agreement, but before four weeks prior to your due date, your doula will refund any payment made beyond the retainer.
§ Unless arranging a payment plan, you will pay the total amount of the non-refundable retainer due at your first prenatal appointment. The full balance is due at, or prior to, the 36th week of pregnancy or upon signing this agreement, whichever is later. We accept major credit cards.
Failure to provide service
§ We will make every effort to provide the services described here. However, in the case of a rapid birth or medical emergency, it may be impossible for your doula to provide these services.
§ If you contact us to advise that you are birthing in good time (3 hours prior to delivery), but neither your doula, nor her back-up is available to attend your birth due to an error on our part or a conflict, we will refund 70% of your total payment responsibility.
§ If you fail to call to advise us that you are beginning to birth, for whatever reason, you will not be due a refund of amounts paid. If there is a remaining balance outstanding, this will be due.
Option to Give Birth at Home
As your doulas, we support your right to give birth in any location that you choose. It is important to know, however, that a planned homebirth is much safer and relaxing than an unexpected homebirth. When hiring a doula, you are not hiring your doula as a midwife. Nonetheless, there have been occasions when some of our birthing mothers decide near the end of labor that they would rather birth at home than leave for the hospital. For some mothers, they are enjoying the familiarity of comfortable surroundings, or the closeness of older siblings, or the intimacy, safety, and privacy that only home can offer. And sometimes, there simply is not enough time to travel due to travel distance, weather, or quick progression or labor (especially with mothers who have given birth previously).
Since more and more families are requesting an unplanned homebirth in labor, we have chosen to address this in our agreement. If you wish, the option to have a planned homebirth does exist and can remain an option until the time of birthing so that you can do what feels right at the time, knowing that you are prepared for either scenario.
When allowing for an option to have a homebirth, you can continue to receive care from your current provider, if you wish. You must also have a minimum of four prenatal midwifery visits prior to the start of labor. There is an additional cost for two of these visits. Kelley will have a birthing team on call around the time of your birth who would come in the event that you decide to give birth at home. In way of preparing for the potential of a home birth, all equipment will be on hand including instruments for perineal repair, resuscitation equipment and oxygen, and other miscellaneous supplies. You will be responsible for purchasing a birth kit prior to the 36th week of pregnancy.
As with any planned homebirth, we never stay home at the expense of safety, therefore, if you choose the option to give birth at home, both mother and baby will be carefully monitored during labor. If any situation arises and we feel that it could become a complication, we would transport immediately and Kelley would continue birthing support in the hospital.
If you have not selected the option to have a homebirth and birth progresses more quickly than anticipated, we will call an ambulance for you. If your baby arrives unexpectedly at home with us present, we will request you or your partner to catch your baby. If you sense that additional medical care is necessary, we will arrange transport by ambulance to the hospital. Under these circumstances, we are not responsible for catching your baby or performing any clinical skills related to the delivery of your baby or his care following birth. Unattended reference guides are available.
q Please check this box if you wish to discuss the option to give birth at home. This option requires additional prenatal midwifery care and a copy of prenatal records must be supplied. If selected, details will be discussed in person.
EXTENT OF CARE
In order to provide quality service this contract stipulates that the care include:
§ Free phone consultation during which you are encouraged to ask questions.
§ Two prenatal visits in our office or at your home.
§ Unlimited prenatal telephone contact during the Doulas normal work hours (9 am to 9 pm) is available. Urgent questions are welcomed 24 hours a day, 7 days a week.
§ Attendance during the birthing according to the parents wishes.
§ Unlimited postpartum telephone contact during normal work hours in the first six months.
§ At least one postpartum home visit.
§ Birth photography with your camera, as desired.
In signing this contract, you agree that we have discussed all the points herein and you understand and agree with them.
______
Client's name Date
______
Doula's name Date
BIRTH DOULA FINANCIAL AGREEMENT - FAMILY COPY
An initial non-refundable retainer of $350 to be paid upon the signing of this contract. The remaining balance of ______is to be paid by the 36th week occurring on ______or at the time of signing this agreement, which ever is later.
If an alternate payment schedule is in effect, payments are due as follows:
In one payment of $______due on .
~OR~
Monthly payments of $ due on the ______of every month,
beginning on the following date ______with the final payment due on ______.
Post-dated checks will be accepted at time of signing.
TERMS
1) The initial retainer payment is non-refundable under all circumstances.
2) If we inform the Doula within four weeks of our due date that we no longer require her services, any payment above and beyond the retainer fee will be refunded.
3) If the Doula should be unable to attend our birth due to an emergency or the circumstance of two clients birthing at the same time, we agree to have her back-up partner as a substitute. If her back up is unavailable as well, we may either:
a) Have our fees returned less $100.00 for each visit or
b) Apply any amount paid beyond the deposit toward postpartum care or other New Life Midwifery services
4) We agree that if the Doula should miss our birth due to a precipitous (very fast) labor or failure on our part to inform her and request her presence she will retain her full fee.
5) If we have a scheduled caesarean section due to breech presentment or some other medical reason, anything paid beyond the $350 retainer will be retained. The full fee will be retained if the doula is to be present with us during the birth and the postpartum hours.
6) Failure to pay may result in collection, unless a payment schedule is agreed upon.
6) Any fees that need to be returned according to item number 2, 3, or 5 will be returned within 30 days.
______
______
Parents Date Doula Date
BIRTH DOULA FINANCIAL AGREEMENT - DOULA COPY
An initial non-refundable retainer of $350 to be paid upon the signing of this contract. The remaining balance of ______is to be paid by the 36th week occurring on ______or at the time of signing this agreement, which ever is later.
If an alternate payment schedule is in effect, payments are due as follows:
In one payment of $______due on .
~OR~
Monthly payments of $ due on the ______of every month,
beginning on the following date ______with the final payment due on ______.
Post-dated checks will be accepted at time of signing.
TERMS