Doulas Look for Greater Acceptance in Maternal Healthcare System

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Marisa Pizarro’s birth, as described by Anemona Hartocollis of the New York Times, starts out on a busy day in her apartment in Lower Manhattan’s financial district. As Marisa labored alongside her doula, her contractions 10 minutes apart, her husband (a music producer) was able to work on an upcoming release, tend to their young daughter, and catch up on the news on his iPad. With the presence of their doula, Marisa labored until it was time to go to the hospital.

The story of Marisa’s birth highlights the role of doulas in the United States:

Doulas are a growing force in the ever-changing culture of maternity, at once a manifestation of the growing demand for personal service (the doorman, the yoga teacher, Amazon Prime) and a backlash against the perceived overmedicalization of birth, with its high rates of cesarean sections.

Medical professionals can express resistance to doulas, and there is no insurance reimbursement for birth doula services. Despite the growing demand of doulas, they are a small part of the system of maternal healthcare. A recent report estimated that “there are as many as 400 doulas working in New York City who attend about 5,600 births a year, or about 5 percent of all births.”

doula (an antiquated Greek word for a female servant) offers support that complements the support from other birth partners (if others are involved). For many women, the support from their doula is

less-fraught emotional support than do sisters, mothers or husbands. They offer tactics to help women manage the pain of labor, as Lamaze breathing classes did to a previous generation. They are familiar faces and patient advocates in a situation where the patient may be meeting the nurses or the obstetrician on call for the first time during the birth. They also consult on prenatal subjects like nutrition and postpartum challenges like breast-feeding.

“We’re not there to change what the parents get,” said Adele Loux-Turner, a doula based in Brooklyn. “We’re there to help get what they want. If there’s a conversation to be had, we do and can let it be known that we’re there to kind of eliminate the hidden menu items.”

Some providers recognize how doulas support mothers in an otherwise impersonal hospital setting. They may recommend doulas, or – at the very least – feel obliged to allow them to honor their presence at the labor. Other providers work closely alongside doulas, and some hospital programs offer volunteer doula services.

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Doulas continue to seek out more recognition from insurance companies, but “insurance coverage is still rare, according to Choices in Childbirth, a maternal advocacy group that released a report promoting doula care last year.”

“Having a baby in New York City is a very lonely thing,” Dr. Jacques Moritz, an obstetrician at Mount Sinai Roosevelt hospital in Manhattan, said.

Yet the benefits of doula care are significant.

In New York, the By My Side Birth Support Program, which has provided free doula services to more than 400 low-income women in Brooklyn, has found that doulas led to a “definite improvement” in breast-feeding, but only a slight reduction in C-sections, perhaps because doulas could not influence hospital policy, said Mary-Powel Thomas, director of the program, a federal and city partnership.

According to Dr. Jacques Moritz, an obstetrician at Mount Sinai Roosevelt hospital in Manhattan, “a doula is like a personal trainer. Not that you can’t do it yourself; it’s just nicer if you have a personal coach for it.” 

For more information about the role of a birth doula, the growing interest in having doula support in labor, and the current state of recognition of doula care, you can read the entire article here, or check out an earlier post discussing the role of a doula.

What is a doula?

Let’s start with what a doula is not.

Doula ≠ midwife. Unlike a doula, a midwife is a licensed health care provider who attends births and performs clinical tasks such as vaginal exams, perineal massage, and fetal heart rate and blood pressure monitoring. A woman’s midwife, nurse, or physician is responsible for assessing the health and well-being of mom and baby, as well as ensuring the safe delivery of the baby.

A doula does not perform any clinical or medical tasks.

A doula does not diagnose medical conditions or give medical advice to the mother. Under DONA’s code of ethics, a doula encourages the mother to speak with her provider or other nurses, midwives, or doctors when she has questions regarding her health or is looking for recommendations. If a doula gives a recommendation to the mother, it is under the condition that the mother check with her caregiver before acting on the suggestion.

A doula does not make decisions for her client. She doesn’t project her own hopes and values onto the laboring mother, and support the mother regardless of any choice.

A doula does not administer any pharmaceutical or homeopathy medications to the mother.

Rather, a doula provides emotional support for the mother in her labor and delivery. A doula works to cultivate the mother’s breath, focus her energy, find comfortable positions, and relax her through massage, words, and other comfort measures. Throughout history, women have been nourished, cared for, and supported in their deliveries by other women. In artistic representations of laboring women, she is depicted next to two women: the first is a midwife, responsible for the safe passage of the baby, as well as the health of the mother. The second woman by her side comforts the mother, addresses her fears and anxieties, and provides emotional support. Today’s doula is the embodiment of the second woman. She soothes, she mothers the mother.

Today, it is common for women to deliver among strangers. Compared to historic birthing practices where women deliver in the presence of familiar faces, this can produce anxiety and stress for the women which complicates or delays her labor’s progress (see here for more information). Furthermore, many of the birth practices in the West cater to the convenience of the physician, yet make birth more difficult and painful for mothers. Reports addressing the dehumanization of this birthing model have found that the role of a doula – someone who’s only role is to support and nourish the mother – provides numerous benefits to the mother and baby.

This doesn’t mean that partners and other caregivers are less effective in providing continuous emotional support. Unlike the partner or other caregiver, a doula doesn’t have the same intimate knowledge and unique awareness of the mother. A doula is able to relieve some of the pressure often felt by the partner, and allow the partner and other caregiver to support the mother according to their own comfort level. Ideally, a doula and partner use their complementing strengths to support the mother in a richer, more complete way than if either were to support her individually.

The benefits of a doula are supported by research. One Cochrane study by Hodnett et al. (2011) found that women who received continuous emotional support from a doula were:

  • (28%) less likely to have a cesarean section
  • 31% less likely to use synthetic oxytocin to induce or speed up labor
  • 9% less likely to ask for pain medication
  • 34% less likely to rate their birth experience negatively

The same study by Hodnett et al. (2011) found that women who were supported by their social network, without a doula, rated their birth experiences more positively, yet did not impact her use of obstetric intervention.

So, what does a doula do? She provides unique, positive benefits for the care of the laboring woman. Doula work focuses on the art of labor support, and she cultivates skills to comfort, soothe, nourish, and empower the mother. By attending to a woman’s emotional needs, the mother’s obstetric outcomes are improved. When a mother receives continuous emotional support, she is less tense, stressed, and experiences less pain in her labor. Women report more positive birth experiences when supported by a doula, and early mother-infant relationships as well as breastfeeding are enhanced. A doula’s continuous emotional support throughout labor has clinically meaningful benefits for the mother and baby.

Helpful references:

Hodnett ED, Gates S, Hofmeyr G J, Sakala C, Weston J. Continuous support for women during childbirthCochrane Database Syst Rev 2011, Issue 2.

Ina May’s Sphincter Theory

Childbirth Connection’s Best Evidence: Labor Support