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CAPPA - reality begins with imagination.
When I was pregnant with my first child, I briefly considered hiring a doula. I saw the doula flyers at Baby Moon, where I did prenatal yoga, and I thought it sounded kind of cool. But when I talked to my husband about it, he felt a little squeamish about the idea. We are both pretty private people (although you wouldn’t think it now that I blog about birth), and he didn’t want anybody else there. He just wanted it to be him and me. And he felt like he would do a good job of supporting me. At the time, it made sense. But hindsight, as they say, is 20-20.
Now all I can say is what were we thinking? How could it possibly be just him and me at the birth, anyways? We were planning to birth in a hospital! A teaching hospital, no less! Where there would be strange residents and students coming and going, and where we had no control over who we got as a labor and delivery nurse. And this was my first birth! It is so important to avoid a C-section in your first birth, because that sets the tone and risk level for all of the rest of your births (and we wanted to have at least 4 children, too). I knew on some mental level that doulas lower the risk of C-section, but I guess I just didn’t realize how important doulas are. Well, I do now. So today, I am going to talk to you about the evidence for having a doula present at your birth.
What is a doula?
According to DONA International, a doula is a professional who is trained in childbirth and provides continuous support to a mother before, during, and just after birth (or during the postpartum period, although I’m not covering postpartum doulas in this article). Doula comes from a Greek word that means “a woman who serves” or “handmaiden.”
What do doulas do?
Doulas “mother the mother.” While performing her role, a doula:
It’s also important for you to understand what doulas do NOT do. Doulas are NOT medical professionals. They do not perform clinical tasks such as vaginal exams or fetal heart monitoring. They do not give medical advice or diagnose conditions. They do not judge you for decisions that you make. They do not let their personal values or biases get in the way of caring for you (for example, they should not pressure you into making any decisions just because that’s what they prefer). They do not take over the role of your husband or partner. They do not deliver the baby. They do not change shifts. You can read more about what doulas do and do not do in the DONA International’s standard of practice for birth doulas written here.
How is a doula different from a labor and delivery nurse or midwife? How is the doula’s role different from the husband’s role?
I don’t know any other way to say this. You are delusional if you give birth in a hospital and you expect your labor and delivery nurse to stay with you continuously throughout your labor. It is literally impossible for a labor nurse to do so. The key thing you need during labor is continuous support. That means that you have someone by your side continuously from start to finish. A doula never leaves your side. Nurses have many other responsibilities other than you. Aside from helping care for you, the nurse is communicating with your care provider, taking care of other patients, documenting care, taking breaks, and taking care of other responsibilities. A nurse’s support ends when her shift does. Also, many labor and delivery nurses are more comfortable taking care of women who have highly medicalized births and may have limited experience supporting women who don’t want pain medication. However, even if you have an awesome labor and delivery nurse who is supportive of low-intervention births, you cannot expect her to stay by your side continuously. The doula only has one obligation the whole time she is with you—and that is YOU!
Sometimes people (like me when I was pregnant with my first child) think that they don’t need a doula because their partner will be with them continuously throughout labor. That’s great that you will have continuous support. Your partner is an essential support person for you to have by your side. However, your partner will need to eat and use the bathroom at times. What will you do while they are gone? What if you have a particularly long labor and your partner needs to sleep while you are laboring? Who will provide you with support then? Also, most partners have little knowledge about birth, medical procedures, or what goes on in a hospital. Asking your partner to be your sole provider of emotional and physical support during labor and birth is like asking your partner to be your sole tour guide in Timbuktu, even though he’s never been there before and doesn’t speak the language. So although your partner is great and is going to hopefully be a great support for you, he has never been to “laborland” before… and he could really use an assistant (doula). Doulas and partners can work together to make up your labor support team. Think of it as putting together the team that will be there for you on one of the most important days of your life. There are a couple of great articles out there about husbands/partners and doulas and how they can work together:
For a husband’s perspective on hiring a doula, read this article from Bloom in Spokane.
For a great example of how a doula and birth partner worked together to help a mom with her un-medicated labor read this blog post written by one of my readers, Cristen.
So what is the evidence for doulas?
In 2011, Hodnett et al. published an updated Cochrane review on the use of continuous support for women during childbirth. They pooled the results of 21 trials that included more than 15,000 women. These women were randomized to either receive continuous, one-on-one support during labor or “usual care.” The quality of the studies was good. Continuous support was provided either by a member of the hospital staff, such as a midwife or nurse (9 studies), women who were not part of the woman’s social network and not part of hospital staff (i.e., a doula) (7 studies), childbirth educators (1 study), retired nurses (1 study), or a companion of the woman’s social network such as a female relative or the woman’s partner (5 studies). In 10 studies, the husband/partner was not allowed to be present at birth, and so continuous support was compared to no support at all. In all the other studies, the husband or partner was allowed to be present in addition to the person providing continuous labor support.
The results? Overall, women who received continuous support were more likely to have spontaneous vaginal births and less likely to have epidurals, any pain medication, negative feelings about childbirth, vacuum or forceps-assisted births, and Cesarean births. In addition, their labors were shorter by about 1 hour and their babies were less likely to have low Apgar scores at birth. What does this mean? It means that if you have continuous labor support (that is, someone who never leaves your side), you are statistically more likely to have better outcomes and your baby is more likely to have better outcomes!
The researchers also looked to see if the type of support made a difference. They wanted to know—does it matter who you choose for your continuous support? Does it matter if you choose a midwife, doula, or partner for your continuous support? They were able to look at this question for 6 outcomes: use of any pain medication, use of Pitocin during labor, spontaneous vaginal birth, cesarean birth, admission to special care nursery after birth, and negative ratings of birth experience. For 4 of these 6 outcomes the best results occurred when woman had continuous labor support from a doula– someone who was NOT a staff member at the hospital and who was NOT part of the woman’s social network. When continuous labor support was provided by a doula, there was a 40% decrease in the use of Pitocin, a 12% increase in the likelihood of a spontaneous vaginal birth, a 28% decrease in the risk of C-section, and 34% decrease in dissatisfaction with the birth experience. These outcomes were better than all the other types of continuous support that were studied.
Why are doulas so effective?
There are 3 main reasons why we think doulas are so effective. The first reason is the “harsh environment” theory. In most developed countries, ever since birth moved out of the home and into the hospital, women have been giving birth in conditions that can often be described as harsh. In the hospital, laboring women are frequently forced to submit to institutional routines (many of which are unnecessary, potentially harmful, and not evidence based—bed rest after your water breaks, anyone?), high intervention rates, personnel who are strangers, lack of privacy, bright lighting, and needles. Most of us would have a hard time dealing with these conditions when we’re feeling at our best. But women in labor to deal with these harsh conditions when they are in their most vulnerable state. These harsh hospital conditions can slow down a woman’s labor, decrease the woman’s self-confidence, and increase the risk of post-partum depression. It is thought that a doula “buffers” this harsh environment by providing continuous support and companionship which promotes the mother’s self-esteem (Hofmeyr, Nikodem et al. 1991).
The second reason we think doulas are so effective is because of the specific interventions that they use. Doulas are skilled at encouraging mobility during labor—encouraging women to use gravity and helping women find comfortable positions for laboring and pushing. Doulas may also reduce fear and anxiety in laboring women. Fear and anxiety are harmful during labor because they initiate the “fight or flight” response, which can increase pain, slow down labor, and lead to abnormal heart rate patterns in baby. Doulas can decrease these harmful effects of fear and anxiety by giving emotional support, providing information and advice, advocating for the woman, and using comfort measures. (Hodnett 2002)
The third reason that doulas are effective is because doulas are a form of pain relief (Hofmeyr, 1991). In fact, doulas can be used as an alternative to epidurals. With doulas, women are less likely to request epidurals (Hodnett, 2011). I used to think the decreased use of epidurals was because a woman might think the doula is watching her like a hawk, making sure she doesn’t get an epidural. However, I have come to realize—through reading the evidence and talking with doulas—that this is not the case at all. If a doula is doing her job appropriately, she will support the birthing woman in all of her decisions, including decisions on whether or not to get an epidural.
So what is actually going on? Why are women with doulas less likely to request an epidural? Well, women are less likely to request epidurals when they have a doula because they just don’t need an epidural as much! Women who have a doula are statistically more likely to feel less pain when a doula is present. Furthermore, by avoiding epidurals, women avoid the entire cascade of events that occurs when you get an epidural—continuous electronic fetal monitoring, IV fluids, Pitocin, drugs to combat low blood pressure, bladder catheterization, and vacuum extraction. Many of these interventions have adverse effects and can increase the risk of Cesarean birth (Caton, Corry et al. 2002).
Based on reading the evidence, I have come up with a conceptual model of how doulas create such great outcomes. A conceptual model is what researchers (such as me) use to try and understand how a phenomenon works. Here is my best shot at a conceptual model on the wonderful phenomenon of doula support. Let me know what you think in the comments below!
In summary, in the words of Dr. Kennell (a researcher who discovered the power of doulas and went on to help found DONA International), “If a doula were a drug, it would be malpractice not to use it.”
How do I find a doula?
If you’re at all on the fence about hiring a doula, I would go ahead and interview a couple with your partner. You might be surprised by how much they impress you and your partner with their professionalism, experience, and knowledge about birth. Childbirth Connection has a great list of interview questions for a doula. They also have a list of websites that you can use to find doulas in your area.
So why would you hire a doula? Based on the evidence, I think the more appropriate question is—why WOULDN’T you hire a doula?
New addition to this article: After getting some feedback on this article, I would like to add a disclaimer. This article does not suggest that you cannot have a good birth experience without a doula. In fact, the evidence shows that the most important thing is for women to have continuous labor support from someone– whether that person is a nurse, midwife, partner, or doula. However, with several birth outcomes (as described above), doulas have a stronger effect than other types of support persons.