Sunday, August 17, 2008

Doulas make a difference

I became a doula with DONA in 2003, a year after I started my PhD program. During my graduate student years, I attended both hospital and home births. I stopped attending births when Zari was born, except for a friend's birth when Zari was 5 weeks old. I brought Zari along in a sling, and the hospital staff were more than gracious to both of us.

I have my reservations about doulas--not about doulas themselves, but about how they may unintentionally support the status quo in our maternity care system. Jennifer Block's Pushed touched on this. There is a much longer discussion of the impact of doula work in Barbara Katz Rothman's Laboring On. Do read Rothman's book; it's well worth the time.

But despite these reservations, I think doulas are a fantastic resource, especially for women planning to birth in a hospital. Early studies of doulas found that their presence decreased the need for pain medication and medical intervention, increased rates of breastfeeding, less postpartum depression, and more positive birth experiences. These studies, though, mostly involved lower-class single women without a husband or partner present during labor. This left questions about a doula's effectiveness for middle-class married/partnered women. A recent RCT (randomized controlled trial) of 420 couples answered this question. The results are phenomenal, although not particularly surprising for those of us involved in doula work.

The findings: having a doula significantly lowered cesarean rates, from 25.0% to 13.4% overall. This decrease was especially marked in induced labors: 12.5% in the doula group vs 58.8% in the control group. (Yikes! 58.8%!?) Epidural rates were also lower (64.7% vs 76.0%), although the difference was not as striking as the reduction in the cesarean rate.

Below is the abstract:

A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates.

SK McGrath and JH Kennell. Birth, June 1, 2008; 35(2): 92-7.
Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio 44106, USA.

BACKGROUND: Previous randomized controlled studies in several different settings demonstrated the positive effects of continuous labor support by an experienced woman (doula) for low-income women laboring without the support of family members. The objective of this randomized controlled trial was to examine the perinatal effects of doula support for nulliparous middle-income women accompanied by a male partner during labor and delivery.

METHODS: Nulliparous women in the third trimester of an uncomplicated pregnancy were enrolled at childbirth education classes in Cleveland, Ohio, from 1988 through 1992. Of the 686 prenatal women recruited, 420 met enrollment criteria and completed the intervention. For the 224 women randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout labor and delivery. Doula support included close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner.

RESULTS: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively.

CONCLUSIONS: For middle-class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula.


  1. I know in my own experience, having a doula only made a significant difference in one of the three births I had them at. But that one was worth it. I needed her, and she was there for me.

    Do you plan to go back to being a doula again?

  2. As a doula, sometimes I wonder how much of a difference I am making. Many times I only feel like a helpless witness to some of the things that go on in some hospitals.

    But, in each birth that I've attended, there has always been that one small moment, when the mother reached out for someone, and I was there to help her. That small moment is what keeps me going back.

  3. Shelly,
    I know how you feel, and that is one of the reasons I am not sure if I'll do doula work again. You really should read Rothman's book, and the excerpt in Pushed, if you haven't already.

    I think a lot of women think that by hiring a doula, they'll get someone who can advocate for them, who can help speak up for their wishes. I really don't think that's a very realistic expectation, because doulas who do that often are met with resistance and/or hostility from hospital staff. Sometimes to the point of hospitals enacting bans on doulas.

    Block raised an interesting point that the doula phenomenon is really a no-confidence vote in hospitals. Women who hire doulas generally feel they must be in a hospital, but by they also don't feel that what happens there is usually in their best interest--hence the doula, in hopes of mitigating these two factors.

  4. When I stopped attending births as a doula (for several reasons many of which have nothing to do with the status quo of maternity care), I felt somewhat relieved that I don't have to wonder if I'm making a difference, and I won't have to watch another labor go off on the wrong track... so I am glad to hear that those who are sticking it out are making a difference! OTOH, I have no doubt the doula phenomenon does enable hospitals to understaff L&D nurses. Bad. Not the doulas' fault. Nurses and/or nurse-midwives should be one-on-one with laboring mothers. If only they could bill labor sitting like they bill surgery... (or if for each possible billable procedure there was an incentive to NOT have done it..)
    Meanwhile, Shelly is so right: those small moments are so priceless. I have memories of potential turning points, too. A gaze in the eye or the right few words whispered, or a practical suggestion to a spouse, and things stay normal.

  5. I don't believe that I've ever been hired to protect families from providers. For all primips I've been hired as a "tour guide" (read that description recently and loved it) for those out of their depth regarding childbirth.

    The one second time mother (and my first call back) I've had used me for about the same reason I as a doula hired a doula to be with me during my second birth (a homebirth after a midwife supported hospital birth - in Ontario) - to be my brain when mine went into birthing mode.

    I don't know about your experiences, but my brain goes really inward and I never remember any of my best laid plans, so my doula does all the interpreting of things that might serve me well at each moment based on my preferences. That's an invaluable service, IMHO.

    The last birth I was at, the parents really needed someone whom they felt they had a relationship with to be their continuity through a long, slow, difficult labour. It wasn't very eventful and my support was overwhelmingly verbal, but at a teaching hospital (both of our hospitals are teaching facilities with scads of residents and interns wandering in and out) having that continuity, through two nursing shift changes, was vital for them.

    Each families needs one little thing from you. Sometimes it's your hands and what you are able to do with them, sometimes it is the wisdom you can draw on and sometimes it's being the quasi-friend with the nurturing attitude.

    I'll have to give those two books a read that you cited.

  6. I think there's a very large problem with women thinking doulas are there to be their voice. It's up to us doulas to correct that (and promptly!) The doula can be there to remember what the mother wants, and remind her of it, but the doula speaking directly to the health care team about what the mother wants both takes away the power of the mother and makes it look like the doula is making decisions for her.
    Please, please, spread the word that doulas don't speak for mothers, but help them find their own voices in order to speak for themselves! :o)

  7. In the last few months, I've been having a crisis of faith in doulas which has kept me away from going through the certification process.

    From a first time mom who then came into the birth community, I learned that doulas tend to represent themselves as advocates and spokespeople for laboring women. But then the same doulas turn around and change the definition of advocate into something that doesn't mean what is being heard when a pregnant couple hears "advocate."

    I also know that I am one of those mothers who found a doula as a no confidence vote in the hosptial. And while I avoided the cesarean, my plan backfired when I experienced PTSD after being forced repeatedly to find my voice in order to speak up for myself like Jen said. I did that and it was like trying to stave off a freight train that was trying to barrel down on me. And Jen is right, it is the responsibility of DOULAS (not mothers!) to correct the misconception that they aren't there to be advocates or spokespeople.

    In addition to all of that, I do believe that doulas are contributing to the status quo of what is happening to women during birth. I see them spending more time trying to make women "more educated" when all that ends up happening is that those women go into the situation that is stacked against them. Doulas should be mounting organized efforts against hospitals and maternity care providers that change the face of birth in hospitals so in time it will become what we know is the true face of birth is supposed to be.

    I see the efforts to make those changes being kept separate from the work od doula-ing. I've heard doulas say "when I'm older, I take on the system but now I'm going to focus on the individual family." While I understand where they are coming from, I strongly think that most doulas have the responsibility to do both: care for their individual familes and take on the system. As they do that work, women will join them.

    This is also a time to say that when I do see doula efforts to take on the system, it is very disjointed and in little pockets. While that is the way grassroots changes come about, its important to connect those pockets and getting them to work together. It is that organized effort that is needed now.

  8. Hi Rixa, thanks for posting this "study". Only trouble is the same trouble with the original doula studies---there's no "control group". The control group would be (possibly) a similar group who had a woman sitting behind a curtain with just her feet visible and not saying or doing anything. When that control was added to the original (poor, single women) studies, guess who had the best stats? Yup, the behind the curtain, do nothing group. Why? That is a question worth mulling and not answering too quickly.

    I not only think it's cruel to delude women that a doula can protect them from N. American obstetrics but I also think it's cruel to delude doulas that they can change an institution that is based on a wrong premise. The premise of a hospital is that birth can and must be controlled. This is where the problem lies. Birth is wild and woolly. . . when it's controlled it simply doesn't work.

    I had a woman in my last doula training who was about to become a grandmother. She was a very smart, very knowledgeable, very experienced nurse. None of that mattered when the obstetric train ran over her grandchild's birth. She advocated fiercely for her daughter and, when her back was turned, they moved in with the interventions.

    I think there's as much hope of having a beautiful birth in the hospital as there is of having an orgasmic sexual experience at a Hell's Angels Clubhouse.
    Gloria Lemay, Vancouver

  9. Gloria, thanks for your perspective on this. The study did have a control group (a group who didn't have a doula at all). It would be very interesting, though, to have another group with a silent woman present, like you described, in addition to the other two that have been studied, in a 3-part RCT.

    I do agree with you on many counts, though, about women thinking they can change the hospital system by hiring a doula. There's just so much stacked against a woman whose wishes go against the institutional grain, that a doula often can't do much to change what happens to the woman.

  10. That was the criticism of the first study when it was pub'd. "No doula" is not a control group that can reliably demonstrate no bias. It has to be a third group to control for bias and someone came up with that idea to put the doula behind the curtain. That group had better results than the doula with mother group. I'll have to find the documentation for you because it was very interesting to me and I love it when research surprises and confounds.

  11. Pregnancy is one of the most important phases of a woman's life and unfortunately sometimes in this phase a woman gets caught in the web of depression. Though depression during pregnancy is not uncommon, it can be dangerous for both the mother and the unborn baby.


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