Doula ? do-la ?!

Proven benefits of doula care

Another great article from Evidence based birth (read the full article there)

According to Dr. Christine Morton, author of the book Birth Ambassadors, a birth doula is a companion who supports a birthing person during labor and birth. Birth doulas are trained to provide continuous, one-on-one care, as well as information, physical support, and emotional support to birthing persons and their partners.

What do doulas do?

Doulas nurture and support the birthing person throughout labor and birth. Their essential role is to provide continuous labor support to the mother, no matter what decisions the mother makes or how she gives birth. Labor support is defined as the therapeutic presence of another person, in which human-to-human interaction with caring behaviors is practiced (Jordan,2013).

Importantly, the doula’s role and agenda are tied solely to the birthing person’s agenda. This is also known as primacy of interest. In other words, a doula’s primary responsibility is to the birthing person—not to a hospital administrator, nurse, midwife, or doctor.

Physical support is important because it helps the birthing person maintain a sense of control, comfort, and confidence. Aspects of physical support provided by a doula may include:

  • Soothing with touch through the use of massage, counter pressure, or a rebozo
  • Helping to create a calm environment, like dimming lights and arranging curtains
  • Assisting with water therapy (shower, tub)
  • Applying warmth or cold
  • Assisting the birthing person in walking to and from the bathroom
  • Giving ice chips, food, and drinks

Emotional support helps the birthing person feel cared for and feel a sense of pride and empowerment after birth. One of the doula’s primary goals is to care for the mother’s emotional health and enhance her ability to have positive birth memories (Gilland, 2010b). Doulas may provide the following types of emotional support to the birthing person and their partner:

  • Continuous presence
  • Reassurance
  • Encouragement
  • Praise
  • Helping the birthing person see themselves or their situation more positively
  • Keeping company
  • Showing a caring attitude
  • Mirroring—calmly describing what the birthing person is experiencing and echoing back the same feelings and intensity
  • Accepting what the birthing person wants
  • Helping the birthing person and partner work through fears and self-doubt
  • Debriefing after the birth—listening to the mother with empathy

Informational support helps keep the birthing person and their partner informed about what’s going on with the course of labor, as well as provides them with access to evidence-based information about birth options. Aspects of informational support include:

  • Guiding the birthing person and their partner through birth
  • Suggesting techniques in labor, such as breathing, relaxation techniques, movement, and positioning (positioning is important both with and without epidurals)
  • Helping them find evidence-based information about different options in pregnancy and childbirth
  • Helping explain medical procedures before or as they occur
  • Helping the partner understand what’s going on with their loved one’s birthing time (for example, interpreting the different sounds the birthing person makes)

Advocacy is a pillar of support that is considered controversial by some for two reasons: first, the word advocacy has several meanings and definitions, and second, doulas differ on their beliefs about whether or not advocacy is part of their role.

In an important paper about the concept of advocacy in the nurse’s role, Kalaitzidis and Jewell (2015) compiled all of the existing definitions of patient advocacy. They found that in the past, the most common definitions of advocacy were “pleading the cause of someone” or “speaking on behalf of someone.” Advocacy can also be defined as “supporting an individual or group to gain what they need from the system” or supporting a person in their right to self-determination.

Advocacy has long been considered an essential component of the nurse’s role. However, while some doulas believe that advocacy is a part of their role, others have been specifically trained that advocacy is not part of their role at all. For many years, DONA International, the first doula training and certification organization, has stated in their standards of practice that advocacy is part of the doula’s role, as long as the doula does not speak on behalf of the client (DONA Code of Ethics, 2015).

Advocacy can take many forms—most of which do not include speaking on behalf of the client. Some examples of advocacy that doulas have described include:

  • Encouraging the birthing person or their partner to ask questions and verbalize their preferences
  • Asking the birthing person what they want
  • Supporting the birthing person’s decision
  • Amplifying the mother’s voice if she is being dismissed, ignored, or not heard, “Excuse me, she’s trying to tell you something. I wasn’t sure if you heard her or not.”
  • Creating space and time for the birthing family so that they can ask questions, gather evidence-based information, and make decisions without feeling pressured
  • Facilitating communication between the parents and care providers
  • Teaching the birthing person and partner positive communication techniques
  • If a birthing person is not aware that a provider is about to perform an intervention, the doula could point out what it appears the nurse or physician is about to do, and ask the birthing person if they have any questions about what is about to happen. For example, if it looks like the provider is about to perform an episiotomy without the person’s consent: “Dr. Smith has scissors in his hand. Do you have any questions about what he is wanting to do with the scissors?”

Taking into account the past definitions of advocacy for nurses, and the desire of many doulas to support the birthing person but not speak in place of them, I’d like to propose a new definition of advocacy in the context of doula care:

Advocacy is defined as supporting the birthing person in their right to make decisions about their own body and baby.

What is NOT included in doula support?

Doulas are not medical professionals, and the following tasks are not performed by doulas:

  • 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 make decisions for the client (medical or otherwise)
  • They do not pressure the birthing person into certain choices just because that’s what they prefer
  • They do not take over the role of the partner
  • They do not catch the baby
  • They do not change shifts (although some doulas may call in their back-up after 12-24 hours)

A conceptual model is what researchers use to try and understand how a phenomenon works. Here is my conceptual model on the phenomenon of doula support.

Conceptual Model Doulas (revised 2017) | Evidence Based Birth®

How is a doula different from having your partner/spouse there?

Some people think that they do not need a doula because their partner will be with them continuously throughout labor. It is true that the birth partner is an essential support person for a birthing person to have by their side. However, the birth partner will need to eat and use the bathroom at times, and they are having their own emotional journey that requires support. Also, many partners have limited knowledge about birth, medical procedures, or what goes on in a hospital, while doulas have knowledge and experience about all of these things that they can use to inform and support both the partner and birthing person. Ideally, doulas and partners can work together to make up a labor support team.

In one landmark study that evaluated the effects of doulas and fathers working together, researchers found that combining a supportive partner and a doula significantly lowered the mother’s risk of Cesarean compared to just having a supportive partner alone. In 2008, McGrath and Kennellrandomly assigned 420 first-time mothers to have routine care (including a supportive partner) or care that also included a professional doula whom they met for the first time during labor. All of the women in the study were classified as having middle- to upper-class financial income levels, having supportive partners, and in the care of obstetricians. During labor, doulas provided continuous support, including encouragement, reassurance, and physical support. They helped the partner support the laboring person, and were careful not to take over the partner’s role.

The results showed a substantial improvement in outcomes for women who had both a birth partner and a doula, compared to having a birth partner alone. The Cesarean rate for these first-time mothers was 25% in the group with a partner only, and 13.4% in the group with a partner and doula. The women who had their labor medically induced experienced an even more striking decrease in the Cesarean rate with a doula—the Cesarean rate with labor inductions was 58.8% in the group without a doula, and 12.5% in the group with a doula. Also, fewer women in the doula group required an epidural (64.7%) compared to those without a doula (76%).

Research has shown that the most positive birth experiences for fathers were ones where they had continuous support by a doula or a midwife. In the McGrath and Kennell study, the women and their partners who had a doula overwhelmingly rated the support of their doula as positive—with 93% rating their experience with the doula as very positive, and 7% as positive. In other studies, fathers have said that when they had labor support from a midwife or doula, things were explained to them, their questions were answered, their labor support efforts were guided and effective, and they could take breaks from the emotional intensity of the labor without abandoning their laboring partner (Johansson, 2015).

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