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“If a doula were a drug, it would be unethical not to use it”
—Dr. Christiane Northrup, OB/GYN, Author of Women’s Bodies, Women’s Wisdom
A Doula (pronounced “Doo-lah”), is Greek word meaning “woman servant”, she is a companion to a woman during labor and birth providing emotional support, physical comfort, education and advocacy. There are many names for these special women: “Doula”, “Childbirth Assistant”, “Labor Assistant”, “Labor Companion”, “Birth Partner”, “Birth Sister” or “Monitrice”. By any name, she is invaluable to the birthing woman.The Labor Assistant/Doula works collaboratively with the woman’s birth partner and her medical team to help her reach her birthing goals. The Doula’s presence helps to make childbirth the beautiful experience it is supposed to be. Don’t give birth without one of these special women by your side!
In all cultures, from the dawn of time to the present, women have been assisted by other women during childbirth. “Doula” is a word derived from Greek which means “woman servant” or one who serves laboring women. Birth art and artifacts from around the world depict the laboring mother supported in an upright position (standing, hanging, kneeling or squatting) with a helper behind her and a woman at her feet. This points towards a human way of birth, and has been called “the classic pose”. The person at the woman’s feet was The Midwife, who caught the baby as s/he emerged from his/her mother’s body.The person standing behind or beside the mother was the midwife’s and the mother’s helper–an auntie, a sister, a grandmother, or a neighbor. She is now known as “The Doula”; a professional labor companion.
Results from the Listening to Mothers Survey II (2006) conducted by Childbirth Connection of 1573 mothers who gave birth in 2005 revealed that technological birth is the norm in the U.S. The executive summary of the report states,”despite the primarily healthy population and the fact that birth is not intrinsically pathologic, technology-intensive childbirth care was the norm. Each of the following interventions was experienced by most mothers: continuous electronic fetal monitoring, one or more vaginal exams, intravenous drip, epidural or spinal analgesia and urine catheter. Half the mothers experienced one or more methods of inducing labor…and a notable minority experienced each of the following: labor that was induced with synthetic oxytocin (pitocin) during labor, artificial rupture of membranes, narcotics, cesarean section (32%), episiotomy, perineal stitches, staff directed pushing and staff member pushing on mother’s belly to help push baby out. Only 11% had Vaginal Birth After Cesarean.” One quarter of the women surveyed said they felt “weak” and “overwhelmed” and used other negative words to describe their feelings about their births.
With few exceptions, the report states, “the forms of care appropriate to low-risk women were not used”. These include use of the birth ball, immersion in a watertub or shower, monitoring baby with hand held devise, eating, drinking, ambulating and laboring in an upright positions and self-directed pushing.
Childbirth Connection states only “a very tiny minority (2%) experienced all of the care practices that promote natural birth”. This snapshot of birth in America sounds grim indeed, but the presence of a Doula can help decrease these interventions.
Childbirth Connection’s Cochrane Review of studies on continuous labor support* (2003, 2007) of American women summarized outcomes reported in at least 4 studies involving at least 1,000 women. Women who received continuous support were less likely than women who did not to:
- Have regional analgesia
- Have any analgesia/anesthesia
- Give birth with vacuum extraction or forceps
- Give birth by cesarean
- Report dissatisfaction or a negative rating of their experience.
“Outcomes include, but are not limited to, lower rates of analgesia and anesthesia use, lower operative birth [cesarean section] rates, shorter labors, fewer newborns with 5-minute Apgar scores less than 7, increased maternal satisfaction with the birthing process, and much more.” (Journal of Obstetric, Gynecologic, and Neonatal Nursing (2006). v31, 6,733 – 741).
Several studies have shown that women who are attended by Doulas have:
- Shorter Labors
- Less Pain Medication
- Fewer Medical Procedures
- Decreased Rates of Cesarean Sections
- Decreased Augmentation of Labor with Oxytocin
- Increased Satisfaction with their Birth Experience
- Better Infant-Mother Interaction
- Increased Breastfeeding Success
- Decreased Postpartum Depression
*Research by Kennel and Klaus of Continuous Labor Support
Provide Physical Comfort and Emotional Support
The doula serves women during labor and birth, providing physical comfort, help with coping methods such as:
- position changes
- emotional support & encouragement
- Informed decision-making
In addition, nine different strategies were distinguished which doulas utilize. Four strategies (reassurance, encouragement, praise, explaining) were similar to those attributed to nurses in published research. Five were original and described as only being used by doulas (mirroring, acceptance, reinforcing, reframing, debriefing).
Emotional support by professional birth doulas is more complex and sophisticated than previously surmised. Mothers experienced these strategies as extremely meaningful and significant with their ability to cope and influencing the course of their labour.
The doula’s role in providing emotional support is distinct from the obstetric nurse and midwife. Professional doulas utilise intricate and complex emotional support skills when providing continuous support for women in labour. Application of these skills may provide an explanation for the positive ‘doula effect’ on obstetric and neonatal outcomes in certain settings. (From the research of Amy Gilland. (Gilland, A. (2011). After praise and encouragement: emotional support strategies used by birth doulas in the USA and Canada, Midwifery, 27(4): 525-31).
Support Fathers and Family Members
Fathers and other family members may feel uneasy at home while the mother is in labor, as labor can be quite intense for some women. Because of this, expectant parents may go to the hospital too soon. For many mothers, the early part of labor can take many hours. During this time, mothers are usually more relaxed in their own homes where they can eat and drink, walk, rest and wait for active labor. A calm environment helps labor progress. The Doula helps create an atmosphere of trust and tranquility, and helps boost the mother’s confidence and puts the father and/or other family members at ease.
Doulas are also a support to the woman’s partner/father of the baby as well, giving him a needed break to eat or rest, reassuring him that labor is proceeding normally and advising him of ways to help the woman cope with labor. Doulas know when to leave the couple alone, respecting their privacy.
Advocate for Mothers and Babies & Act as Healthcare System Navigator
When labor presents challenges as it often does, the doula can help the couple understand their options and make an informed decision.The Doula is an advocate for the laboring woman, helping to communicate her needs and desires to the hospital staff and help the woman achieve her birthing goals. Going to the hospital in early labor can lead to unnecessary medical procedures such as cesarean section surgery. There may be strict time limits for labor progress, restrictions on the mother’s movement, and eating or drinking in labor may not be allowed. The presence of a Doula can help the woman cope with these obstacles. These restrictions of movement and imposed time limits can either slow labor down, make labor more painful and harder for the woman to tolerate, and increase the possibility of receiving pitocin to make labor stronger and go faster (“augmentation”). This can make labor more painful for the mother. As time passes, and labor becomes more intense, the woman may want pain medication. While that is always an option, there are side-effects on labor, woman and baby. The Doula can offer education, helping the woman and her partner make informed choices, and often lessening their need for medical interventions.
Promote Evidence-Based Maternity Care
The following care practices are endorsed by Lamaze International and the Coalition for Improving Maternity Services (CIMS), which developed the Mother Friendly Childbirth Initiative, 10 evidence-based steps to improve maternity care.
Lamaze’s “Six Care Practices That Support Normal Birth” represent “evidence-based care which is the gold standard for maternity care worldwide. Evidence-based care means using the best research about the effects of specific procedures, drugs, tests, and treatments, to help guide decision-making.” (Lamaze, 2009). The practices are:
1. Labor begins on its own.
2. Freedom of movement throughout labor.
3. Continuous labor support.
4. No routine interventions.
5. Spontaneous pushing in upright or gravity-neutral positions.
6. No separation of mother and baby after birth with unlimited opportunities for breastfeeding.
The Coalition for Improving Maternity Services (CIMS), “a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families” developed The Mother-Friendly Childbirth Initiative (MFCI) and “The Ten Steps to Mother-Friendly Care” which are evidence-based recommendations for maternity and newborn care (CIMS, 2009). The evidence for the recommendations were published in the peer-reviewed Journal of Perinatal Education (2007). To download the document: click here
Mothering the mother, Postpartum Doulas provide knowledgeable, nurturing care for the postpartum woman and her newborn. They may instruct on baby care and breastfeeding, cook nutritious meals and run light errands. Studies by Kennel and Klaus showed that doula care improved breastfeeding success, decreased postpartum depression, increased maternal satisfaction and promoted better mother-infant interaction (MH Klaus, JH Kennell & PH Klaus, Mothering the Mother, New York: Addison-Wesley, 1993).
Postpartum Doulas nurture new mothers and newborn children with tender loving care. “Mothering the Mother” allows the new mom to focus on recovering from childbirth and nurturing her baby. Postpartum Doulas help new dads too! Fathers can enjoy their newborn knowing that meals are being prepared and their newborn baby and his/her mother are in good hands while they’re at work.
Services may include the following:
- Breastfeeding Consultation and Instruction (Hospital, Home or Telephone)
- Grocery Shopping & Errands
- Meal Preparation
- Newborn care instruction
- Herbology & Homeopathy
- Baby-Friendly Approach in Hospital
- Kangaroo Mother Care
- Baby Laundry
- Physical Care of Mother and Newborn
- Infant Massage Instruction
- Prenatal and Postpartum Massage for Mom
- Newborn Assessment
- Emotional Support for New Mom (and Dad too!)
- Referrals to complimentary services (massage, acupuncture, chiropractic, herbal medicine, naturopathic practitioners, etc.)
Community-based doulas provide an expanded role than traditional doulas whose focus historically has been to provide support during labor and immediate postpartum. Community-based doulas work with women throughout prenatal period as well as the birth process and immediate postpartum. In this expanded role they are more like community health promoters with in-depth knowledge of pregnancy, childbirth and breastfeeding. As caring and trusted companions, they provide social support to reduce stressors associated with preterm labor, support health behavior change in their clients and provide health education information to help optimize empowerment through childbirth and successful breastfeeding. Community-based doulas are from ethnic communities where maternal-infant health disparities exist or are among marginalized communities at highest risk for poor pregnancy outcomes.
Persons wishing to become a Certified Doula should contact the following organizations which train labor and postpartum doulas. They are:
Happy Mama Healthy Baby Alliance (HMHBA) –Perinatal Support Specialist Advanced Doula Training or Postpartum Doula Training
Doulas of North America (DONA) – Find a local instructor
Childbirth and Postpartum Association (CAPPA) – Birth Doula or Postpartum Doula