The Doula Book

More recently, concerns have been raised about rising rates of cesarean sections and the highly technological and impersonal nature of childbirth. These trends have led us, together with colleagues, to study the effects of restoring the role of women helpers in the childbirth experience. Our research has now demonstrated that continuous support from an experienced labor companion can be dramatically beneficial. As we will show in the later chapters of this book, in studies of over 16,000 women comparing outcomes with and without such support, we have seen a major reduction in the length of labor, a greater than 50 percent drop in cesarean sections, a remarkable drop in the mothers' need for pain medication, and several other important and measurable benefits, which we describe in the chapters that follow.

This continuous support is provided by caring, experienced women we call doulas. In searching for a term to describe this role, we wanted a word with a nonmedical connotation that would stress the value of a woman companion as attentive and comforting. We turned to the Greek word doula, meaning "woman caregiver." Our first exposure to the word came from Dana Raphael's use of the term to describe "one or more individuals, often female, who give psychological encouragement and physical assistance to the newly delivered mother."¹² We use the word in the now widely accepted sense of an experienced labor companion who provides the woman and her husband or partner both emotional and physical support throughout the entire labor and delivery, and to some extent, afterward. Other people use terms such as labor coach, monitrice, childbirth assistant, labor companion, or mother assistant. Whatever the term, we hope our readers will come away with an understanding of the vital shared ingredient that makes this role so powerful and beneficial. In this book we describe what a doula can provide both during labor and birth and in the postpartum period, and how she is trained. We discuss the results of our studies on labor outcomes and differentiate not only between the assistance of a doula and the equally vital help of fathers but also between the work of the doula and that of the nurse, physician, or midwife. We also offer guidance in finding and evaluating a doula, and give, in Appendix A, information on how a doula is trained.

We realize that a woman having a baby may be married or single and accompanied by the father, her own mother, or a close friend.When we use words such as father, partner, couple, and parents, we mean to include all types of family arrangements. Also, for simplicity, we use the words mother and father, rather than mother-to-be and father-to-be, for a woman and man as they share in the experience of labor and delivery.

Given these hopes and fears, all mothers and fathers need emotional support and help during labor. Much of this support they can provide to each other. The mother needs to feel the father's care, love, sense of connection, responsibility, and sense of sharing in the intimate experience of bringing their child into the world. The father or other chosen partner has a strong desire to help, to participate, to feel useful and active, and to feel important and necessary for the mother.

But when two people share an emotional bond and an ongoing relationship, it is very difficult for that companion to remain continuously objective, calm, and removed to some degree from the mother's discomfort and fears, or any danger to her. In most cases—and this cannot be stated too often—the father will have the unexpressed but deeply felt question, Will everything be all right? Also, a father often has had little or no experience with the birth process.

For these reasons, every woman in labor needs not only the father or other chosen partner but also a nurturing, experienced person—a doula—who can calmly and skillfully help her cope with labor and be a reassuring and constant presence for both her and the father. The doula gives a level of support different from that of a person who is intimately related to the woman in labor.

These two kinds of support complement each other. A doula can help a woman work with her labor and guide her on how to stay relaxed and comfortable at home until labor is well established. Prenatally, the doula can show the pregnant woman how she will have the ability and confidence to be an advocate on her own behalf. In the hospital the doula can help the father or other partner be less anxious. With her practiced skill, the doula serves as a role model for the less experienced person.

Very often the couple worry that an outside support person will take over and control the labor experience, as many individuals providing labor assistance have traditionally done. The training of a doula is quite different, emphasizing quiet reassurance and enhancement of the natural abilities of the laboring woman. A doula is constantly aware that the couple will carry the memory of this experience throughout their lives. As we discuss in Chapters 3, 7, and 8, the doula is there to help the parents have the type of birthing experience they want.

For millennia the relationship of mother to daughter, of older experienced woman to younger birthing woman, was respected and understood. Today, although many women may want their own mothers' help during labor, most of today's grandmothers are not experienced around birth. The experience of women who gave birth in the 1960s and 1970s may not have been ideal. Also, many women are distant from their adult daughters geographically and some, psychologically. Many expectant women today prefer not to have their mothers at the actual birth, even if they have a caring relationship. Many prefer to have the father present, and it is often easier for the couple to have a nonrelated but caring person help them. Sometimes men who have become involved in birth through childbirth courses may feel their position is usurped if their mother-in-law or a close friend of the mother's is acting as the main support during labor. Though laboring women's mothers and friends can offer important support along with fathers, a doula's nurturing, helpful, and objective support relieves the family member chosen to be present from sole responsibility for the labor. It is not an attempt to interfere with the relationship between the woman and her partner or other family member.

In no other area of the hospital is a family member asked to take on such a significant caretaking role as in childbirth. When working in the obstetrical unit, we have often been struck by how terribly relieved fathers are when an experienced nurse or midwife enters the room and remains with them. This feeling of relief enables fathers to be much more relaxed, loving, and emotionally available than when they bear the burden of responsibility alone.

We therefore want to enable the father to be present at his own comfort level and to remain emotionally connected to his partner and child. Few fathers want to be—or should be—the sole support person in the room. As we discuss in Chapter 8, the mother gains more assured, steady emotional support from her partner if he is less worried about what he is supposed to do and if they both can relax and trust the doula's expert care. As one father noted: "I've run a number of marathons, I've done a lot of hiking with a heavy backpack, and I've worked for forty hours straight on call; but going through labor with my wife was more strenuous and exhausting than any of these other experiences.We could never have done it without the doula. She was crucial for us." His wife added: "I want the doula there to assure me that everything is fine and to comfort me. I want my husband there for emotional support."

A laboring woman's rapid changes of mood may alarm an inexperienced father and compound the mother's fears. "If you leave the mother alone for even five minutes," a doula commented to us, "she begins to become distressed. She begins to fall apart and lose control, and when you return, it may take a half hour to get her settled down." Fathers express feelings of mounting anxiety. Underlying this anxiety is often an unexpressed fear of danger for the mother or child, as well as distress for the mother's pain. Although fathers have many positive feelings and great anticipation, these negative feelings can get in the way and, in turn, affect the progress of the labor itself. Over and over again we have been impressed by the calming influence the doula has for both the mother and father as she explains what is happening, uses her extensive experience to help the mother, and supports the parents in having the kind of experience they originally desired.

On one end of the spectrum, childbirth is viewed as a normal physiological event that follows a natural course. Interventions needed for these natural deliveries are seen as minor, although the personnel must remain alert for any medical sign of complications. When childbirth is planned from this point of view, mothers are informed what to expect during the start of labor and, after checking with their caregivers, given the okay to stay at home during most of labor. They are guided to stay relaxed, take in fluids and light food as desired, rest, do distracting activities in early labor, and as labor progresses help with a variety of comfort measures.These include relaxation, visualization, massage, position changes, shower, or bath.At the hospital they are further helped to work in a natural way, allowing their labor to continue without interventions (rupture of membranes, augmentation with pitocin). Minimal medications are used, and mothers attempt to give birth without an epidural. Episiotomies are kept to a minimum, and most mothers give birth vaginally.³

On the other end of this spectrum, childbirth is seen as a medical event fraught with potential danger. For many mothers giving birth in such a setting, labor begins with an induction between Monday and Friday. Other women, whose labor begins at home, are usually asked to come into the hospital early. There, they are monitored and receive IV fluids, and they are often limited to bed and unable to drink or eat. Often the membranes are ruptured, an early epidural is given, and contractions are augmented with pitocin. These mothers have a higher rate of cesarean sections and a higher rate of episiotomies. Many maternity hospitals or obstetrical practices, of course, fall in between these two extremes.

In planning or thinking about their own delivery, expectant parents should know about the different practices of the physicians and midwives in their community. By knowing which approaches these professionals tend to adopt, they can make a more informed choice in order to meet the mother's medical, emotional, and physical needs.

Studies by Ellen Hodnett in Toronto noted that women planning a hospital birth rarely expected to have a nurse with them throughout labor.⁴ The women usually felt the nurses would be busy or viewed their role as purely technical. Hodnett commented, "Recognizing that laboring women require psychological support and realizing that nurses have little time to give it, hospitals have increasingly permitted and encouraged husbands to assume active roles in the care of their wives during labor." In addition, in hospitals many different caregivers are often involved with one mother. A recent study found that women giving birth encountered an average of 6.4 unfamiliar professionals during labor. The presence of many strangers can disrupt the labor and confuse the mother.

At home and in some hospitals, midwives who care for only one mother at a time, continuously attending each mother from early labor on, meet both the medical and emotional needs of the mother and father. When a hospital or other birth setting provides such continuous one-to-one nursing or one-to-one midwifery care and that caregiver's goal is to reassure, relax, comfort, and inform the mother rather than to tend only to the needed medical interventions, that person takes the same supportive role as a doula. Many nurses who care deeply for the emotional as well as the physical well-being of their childbearing patients are happy when they can provide such uninterrupted care.

In most cases, however, nurses on the delivery floor and hospital-based midwives generally care for several patients at one time, monitoring the progress of labor; the vital signs of the mother, such as heart rate, blood pressure, and temperature; and fetal well-being, with heart-rate changes. In non-high-risk situations obstetricians and family physicians are not in constant attendance but check in and out until late labor. Then they manage the delivery and attend to any medical aspects, giving strong support when they are present.

Many parents expect to handle childbirth alone, but within the circle of a "safe" hospital setting where help is just outside the door. Many nurses believe they should not interfere with labor and, instead, just come in to check on how things are going. When they or the physician come in only intermittently, they may not always recognize the great need that parents have for information and reassurance. It may be difficult for the father to ask for help or to realize when or what type of assistance his wife needs at each stage of labor. He may be getting anxious, and he will often think of "help" only as a medical intervention rather than as assistance with the emotional needs of the mother as she works through contractions.

Two widely respected, experienced, and caring teachers of obstetrics, Drs. Kierin O'Driscoll and Declan Meagher, who created a one-to-one midwifery support program in Dublin, have recognized the negative effects that a lack of support has on women in labor.⁵ When a woman does not have an experienced person to give her continuous personal attention throughout labor and when the father is uncertain, fearful, or becoming anxious himself, they note,"the scenario for many can be written in advance: the woman becomes progressively withdrawn from contact with her surroundings, closes her eyes and buries her face in the pillow, only later to become increasingly active, with contorted features and restless movements, interrupted by outbursts, until finally a state of panic is reached and self control is lost." In our studies we have encountered several occasions in which couples who were reluctant initially to have a supportive companion because they wanted to be alone for this significant event changed their minds completely in midlabor and pleaded with us to supply them with a doula. The role of a doula is still being refined, and as we said earlier, labor support can be offered by several other types of professionals. Its essence, as we will show, is a "mothering" role, mothering both the mother and father as they are born into their new family. In Appendix A we describe the basic ingredients of doula training.

Our studies have led us to the firm conviction that a doula—a person providing unobtrusive, compassionate, and experienced support throughout labor—is needed by every couple during the delivery of their child. With such help, parents can capture the special moments and priceless experience of their own unique childbirth. This in turn becomes the foundation for strong attachment as the new family comes into being.