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The role of a doula and the value of doula support

The term “Doula” has its origins in Ancient Greece and is most commonly translated as female maidservant (1, 2). Doula refers to a woman who is trained and has experience in, assisting and supporting a woman through pregnancy, labour, birth and/or the postpartum period.  Modern or current interpretations of a doula’s  role remain embedded in her ancient Greek origins. Doulas remain mostly female and their role remains as a trained and experienced support person for women throughout their pregnancy birth and postnatal period. The role of a doula is to support a woman in labour, wherever she chooses to give birth – a hospital, at home, or in a birthing centre.  Doulas provide continuous physical, emotional, spiritual, informational and educational support from when a woman is pregnant, to birth, after birth and when the baby is brought home.  It is important to note that a doula is not a midwife, nurse, or medical practitioner.  Doulas do not provide medical, nursing, midwifery care, nor will they comment on, interpret, or judge the care that is provided.  Some doulas are able to offer therapeutic support services such as massage, parenting/birthing education or homeopathic. However this is not their primary role. They are there in a purely advisory and supportive capacity.
"...every effort should be made to ensure that all labouring women receive support...this support should include continuous presence (when wished by the mother), the provision of hands-on comfort, and praise and encouragement." (Enkin et al 1995, p. 295)

Women in labour have special emotional needs that are often undervalued within the current dominance of medicine in childbirth (3).  Where once women, women carers and midwives defined and controlled birthing practices in a short period in time these changed to be dominated by medical scientific knowledge controlled within the hospital space(3: p. 3).  Personal context and emotional spiritual beliefs and needs have been devalued as the frame for understanding childbirth has been redefined as medical and task orientated (4).  Our present culture does not provide many opportunities to understand and appreciate the awesome power of childbirth.  Having a doula present during labour and birth can help parents appreciate the value of the experience and their important role therein and give them the confidence to face the challenges of parenthood.  A doula’s support can help the mother have a safe and healthy birth experience that is meaningful and satisfying to her and her partner.

 


 

Doulas work as part of a birth team.  Their knowledge and experience can help partners; family and/or friends participate comfortably and effectively at the birth. The doula can give the other support people ideas, some reassurance and a rest.  Her greatest role is to "be there for the woman" and help her have the best possible birthing experience, and she does this by working with whoever else is there - and by supporting them also.  A doula can never replace the love and caring that family and friends can provide during the birth experience.  No one else can fill this special role. A doula has particular skills, however, in providing an emotional connection and support to enhance the quality of support and care a woman receives from those around her and to offer this to women who may not have a supportive network/family or partner.

The day a woman gives birth is one of the most important days of her life.  It is a day she will remember clearly for the rest of her life.  Every woman remembers her birth story (5). She does not just have a baby - she becomes a mother.  Her partner becomes a father.  A new baby is born and grandparents, aunts, uncles and whole families and communities welcome a new person into their lives.

Typically, birth doulas are also known as labour assistants or birth support people.  They meet with the mother and her partner during the pregnancy to get acquainted and discuss the birth.  They offer continuous emotional support from early labour through to the birth of the baby.  During labour they help with breathing and relaxation techniques and may provide massage, they make suggestions on position changes for comfort and labour progress and offer frequent reassurance.  Doulas offer non-drug techniques to ease labour discomfort, facilitate labour progress, and avoid complications and unnecessary medical interventions.  Doulas also importantly advocate for couples to follow their birth plans and ensure that any diversion from their plans are understood and agreed upon by them.


 

Doulas can possess a variety of skills such as: evidence to support informed choice, physical support including massage, acupressure, touch and application of hot or cold compresses and emotional/spiritual support including praise and encouragement. Doulas are skilled at creating and holding a space in which the woman will birth. They personalise their approach to suit every mother’s individual needs.

Doulas are also able to provide professional care and assistance at any time, access to resources and information so that people are able to make informed choices about their pregnancy, labour, and childbirth.  They offer referrals to classes such as antenatal fitness, birth preparation, lactation classes, pregnancy yoga, and also to pregnancy massage services if they do not offer these services themselves.  They offer assistance in preparing for the birth, such as creating a birth plan, preferences or a plan of action.  They offer post-natal support with breastfeeding or referral to a lactation consultant if required and they support the father.  General support and care is available when the baby is first brought home.
Postpartum doulas are experienced and educated women who offer emotional support as well as physical care and practical assistance in the first days after the baby is born.  They help the mother learn to care for her baby and guide her efforts at breastfeeding the baby.  They may provide household assistance, meal preparation and baby laundry.

A doula is someone who brings comfort and joy to new mums and dads. What they do at birth depends on what women and families want.  Does the woman want constant verbal encouragement?  A doula can be the woman’s own personal cheering squad.  Or how about massage?  She’ll offer to rub away the tension in her clients back, neck, shoulders, feet, or wherever she needs it most.  Is the woman afraid her partner won’t remember everything from the childbirth classes?  Or maybe he’s concerned about being first in line and he’s never even seen a birth in real life before! 

Women and partners can decrease their worries because a doula can keep them informed during the birth process so that they will always know what they might experience next.  A doula will offer suggestions for family and friends, too.  Doulas support many women giving birth, as well as their partners and older children; they are competent and knowledgeable and can be relied upon for this specialised assistance.

Within the dominance of institutionalised childbirth it is common that the midwife or doctors are involved in the medical aspects of birth, whereas at all times a doula keeps the mother as the centre of the world.  Doulas know that a calm and confident mother gives birth easier and has fewer complications.

So what is the benefit to women?

A doulas primary job is to assist a woman to have the best possible birth experience, as she defines it.  A doulas primary responsibility is to the mother - not the doctor or midwife, nursing staff, hospital administration, not even her partner or family. Doulas take on the mothers values and make them our own and help her to be understood.
-Penny Simkin, DONA co-founder (6).

It is well known in the birthing community that doulas are a unique and vital part of the birth team.  Evidence clearly shows that having a doula decreases women’s chances of having complications - making pregnancy, birth and the early days with her newborn easier (3,4,5,7,9, 10).

Research (10) indicates that the presence of a Doula:

  • Decreases the need for caesarean by 50%
  • Increases the chances of unmedicated birth 30 - 60%
  • Decreases the length of labour by 25%
  • Decreases the need for other interventions with mother and baby
  • Increases the mother's and father's satisfaction with the experience

The benefits of having a trained Doula are many.  Studies have shown Doula’s to be the single most effective 'pain relief' available! 
Having a Doula at your birth has been proven to: shorten labour; significantly reduce caesarean rates, forceps or ventouse; significantly lessens the mothers wish/need for pain medication; improves mother’s perception of her experience, her ability to cope and her self-esteem; lowers anxiety and reduces post-natal depression; has a positive effect on breastfeeding and mother-baby bonding; improves the well-being of the baby (3, 10).

"Every woman needs not only the father and other chosen partner but also a nurturing, experienced person - a doula- who can calmly and skillfully help her cope with labour and be a reassuring and constant presence for both her and the father." Klaus et al 2002, p.6.

6 weeks after birth, mothers who had doulas were:

  • Less anxious and depressed, higher self esteem
  • More confident with their baby
  • More satisfied with their partner
  • More likely to be breastfeeding
  • reduced caesarean section rate by 40%
  • decreases labor by 25%
  • use of oxytocin by 50%
  • pain medication by 31%
  • forceps reduced by 34%
  • epidurals 10 – 60-% (3. p. 97 – 98)

Cost and value of a doula

Having a doula for the mother in labour has many values. The initial value is prior to the labour.   It begins during pregnancy, which starts as relationship building that will encourage the mother's ability to relax, with her doula’s help, based on a relationship of trust that has been built and established during this time.  The doula can help point the mother in the right direction for obtaining more information in order to better educate her as to what her options will be for this upcoming birth.  A doula is usually available by telephone or email to answer questions that arise during the pregnancy.  In labour the doula can act as an advocate for the couple.  She can also be the clear mind that will help the couple achieve the birth that has been planned for.  The woman will need mothering during labour and birth; a doula can act as this mother without the emotional entanglements that sometimes occur when it is actually the woman’s own mother (3. p. 5 – 6).  After the birth, a doula can assist in helping the bonding time to go smoothly and offer assistance with breastfeeding, if it is needed.
Hiring a doula is an investment, and it can be an integral part of creating a birth experience that women and families can look back on with joy.  The cost will depend on the doula’s level of experience, the amount of time that she is required before and after the birth and also any other services that she may offer such as pregnancy massage, aromatherapy or birth photography.  When selecting a doula, it is a good idea for women to interview a few first, so that they find someone that they are comfortable with.  Doulas will charge anywhere from $400 to $1500 to support a birth depending on qualifications and packages they offer.  This may seem like a lot of money, especially when money is tight after a new baby arrives; however engaging a doula is definitely a gift worth giving.  When a doula sets her fee, she has to take into consideration her education and training costs, her experience, ongoing research, certifications, professional fees, and all the costs of running a small business.  While doula’s services may be seen as an expense they are a valuable service and deserve adequate financial compensation.  The savings that are undefinable include positive birth experience, decreased use of drugs and interventions, which have a cost to women’s and babies’ health and immediate and long-term wellbeing, decreased postnatal depression, greater initiation and success in exclusive breastfeeding – a significant health benefit to the baby and higher positive parenting beginnings (2,3,4,5,8).  It would be a positive step if the cost benefits to the health care system could be better supported through governments by offering rebates to women for doula services (3. p. 96 – 97). Our current government is currently conducting a maternity services review, which should see some changes to our system.  Our insurance providers need to get on board and it’s up to each of us as consumers of maternity services to stand up and ask for these changes to occur.

Doulas are not typically paid by the hour; they stay with women no matter how long the labour is.  Doulas are passionate about the women they support; they love being a doula and will go above and beyond to provide you with unique, celebratory service. 
All doulas do great work, however some offer a variety of services such as: Aromatherapy, candles, oils, and music playing in the background while keeping that beautiful ambient birthplace sacred so women can feel relaxed and soothed and safe – a good doula knows how to keep a positive space.  A good doula will have a bag of tricks with her; massage tools, hot packs, breath mints, and lip moisturizer, hair ties and a few surprises.  For example a doula will be able to source and provide women with mother’s milk herbal teas, custom mixed herbs and oils and lanolin to soothe sore nipples.  She will most probably offer photography, taking as many or few pictures during labour and after.  She’ll likely catch the kiss a husband sneaks between contractions, the overwhelming joy as the woman lifts her baby up to her breast or those first precious snuggles with a newborn.  A doula will not want to be the stranger in the corner but more of a trusted friend.  When women have pre-natal visits it will be up to the woman to discuss anything from birth plan consultations to just listening to women debrief about previous births or suggesting ways to get through the last few uncomfortable weeks.  Some doulas provide additional services for childbirth education either one on one or in-group sessions or they will attend previously organised classes with her client.

Medical Benefits of Hiring a Doula

“If a doula were a drug, it would be unethical not to use It.”
 Kennell, 2002. p. 213-214.

As noted above there have been numerous studies in the last 25 years that clearly demonstrate the value of a birth doula during the process of childbirth (3,4,7,8,10).  Evidence has shown that fewer mothers ask for medication or require medical intervention such as the use of oxytocin to induce or speed up labour.  Mothers who use doulas are more likely to have shorter labours and fewer caesareans compared to mothers who did not have a doula.  Mothers also tend to breastfeed their babies’ longer and have a more satisfying birth experience if they have used a doula.  In fact, a recent survey indicated that mothers gave the doulas the "highest rating" for the best supportive care over any other member of the birth team including nurses, doctors and midwives. Long term benefits continue as evidenced by research (4. p. 05 – 109)
Parents can have many reasons for hiring a doula that may or may not have anything to do with the research results.  There are a host of reasons parents may want to use a doula.

Other Reasons Parents hire a Doula (2, 3, 10):

  1. A desire for additional support during labour, with or without a primary labour partner.
  2. A history of a previous long or challenging birth.
  3. Greater access to non-pharmacologic methods of pain relief.
  4. Mothers with special needs such as those planning a VBAC (vaginal birth after caesarean), single mothers or those who cannot use pain medications such as an epidural.
  5. For additional help with breastfeeding techniques and postpartum support after birth.

How doula support is unique

“I couldn’t and wouldn’t practice obstetrics today without doulas. They give me the confidence of knowing the laboring mother is not frightened or alone, and is always in the capable hands of a professional labor assistant. The quality and continuity of care should not be regarded as a ‘fringe benefit,’ ‘an extra,’ but as an essential and irreplaceable part of the birthing experience.” Harlan Ellis, M.D. quoted in Special Women by Polly Perez (8).

In terms of support, guidance and caring, care that will meet their own needs women assume they will gain this from the midwife caring for them in labour, however it has been shown by Henlet – Einion (9) that women find that in labour their own needs and expectations take second place to the policies and routines of the hospital.  Labour wards are driven by issues of staffing, policy and routine practice and cannot provide within this the same quality of woman centred care that a doula can. The reality is that the typical labour ward in the hospital has multiple clients.  Midwives in a typical labour ward are required to keep extensive records on all of their women at the same time.  Midwives in Australia have extensive governmental and institutional restrictions that inhibit their ability to practice within the full scope of their role. 1-2 % of women birth at home therefore independent midwifery is limited leaving the majority of midwives working in hospitals.  Some midwives are able to work in more autonomous situation such as in birth centres and group practices but this is again a minority.  Hospital systems are notoriously limited in providing personalised woman centred care and women are too often expected to fit into the institution rather than the institution fit to women’s needs.  Doulas provide an essential aspect of woman centred known continuity of support and care to women that is currently very lacking for the majority of women in Australia today. 

Doulas do not work in shifts nor have multiple clients. Many only take on one woman a month.  They care for the individual needs of the mother and stay with her until the baby is born.  Not only that, the birth doula is not a stranger to the mother and therefore she can act as a familiar guide through the long and often challenging hours of labour.  Only independent midwives and our birth centres with dedicated midwives can cater for women who prefer continuity of care.  Luckily in a birth centre midwives are able to share their case load as a group and be more available to women, an arrangement which synchronises beautifully with doula care.

Parents are also discovering that having a midwife with them during labour also does not guarantee one-to-one support or the guidance and care they had hoped for.  The limitations to midwifery care through the fragmented systems of care in which those midwives have to work mean that they  are busier than ever and often cannot provide individual, continuous attention to mothers in labour, especially in hospital settings. Policy, hospital norms, increasing medicalisation of childbirth and endless paperwork have resulted in many midwives working to meet the needs of the workplace rather than the needs of women according to a study by Hausman (7) and their skills in their midwifery role become more defined through medicine and limited to tasks rather that whole of women care.

Birth is highly valued in our society but improvements may be possible and women should be the centre of the care provision.  Doulas address some of the inequalities in maternity care, using strength passion and expertise they work hard to place women at the centre of their care and value birth which is how it once was and must be again. A doula unquestionably strengthens the mother’s ability to birth in a way that stimulates her natural power within.  It is important to give the mother confidence in herself and her body.  Families gain significant benefits by having a doula, ensuring their unique journey into parenthood is filled with peace, love, beauty, grace and wisdom (12)

Reference List

  1. http://en.wikipedia.org/wiki/Doula#Etymology_and_history_of_usage
  2. Raphael, D. 1973 The tender gift: Breastfeeding, Englewood cliffs, NJ: Prentice-Hall
  3. Klaus, M, Kennell, J and Klaus, P. 2002. The doula book. Da Capo Press Books.
  4. Scott, K.D., Berkowitz, G., Klaus, M.. 1999. A comparison of intermittent and continuous support during labor: A meta analysis. AM J Obstet Gynaecol, 180:1954 – 1959.
  5. Gibbins, J. and A. Thomson (2001). "Women's expectations and experiences of childbirth." Midwifery 17(4): 302-313.
  6. Simkin, P. http://www.pennysimkin.com/
  7. Hausman, B. L. (2005). "Risky buisness: Framing childbirth in hospital settings." Journal of Medical Humanities 26(1): 23-38.
  8. Perez, P. 2000.  Special Women: The Role of the Professional Labor Assistant. 3rd Edition . Cutting Edge Press
  9. Henley – Einion, A. 2003. Chapter 11. The medicalisation of childbirth. The social context of birth. Squire, C. ED.
  10. Enkin, Keirse, Renfrew and Neilson.1995. A Guide to Effective Care in Pregnancy and Childbirth - Oxford University Press.
  11. Kennell, J. 2002. Doulas: Into the Mainstream of Maternity Care.  Birth.  25:4. P. 213 - 214
  12. Hriskin, H. 2008. Client pamphlet, Belly, Birth & Beyond. www.bellybirthandbeyond.com.au

 

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