Pregnancy & Birth

Labor Support Doulas

The word doula (pronounced DOO-luh) comes from ancient Greek and translates to “handmaiden or servant.”  Labor support doulas, or childbirth attendants, are women who are trained to attend to the social needs of the laboring mother.  Doulas perform no medical or clinical tasks.  For instance, doulas may offer words of encouragement, suggest new positions for labor, rub the mother’s tired feet, run errands, or make calls to family members. The key component of doula care is the nurturing and caring presence of the doula. As doulas like to say, they “mother the mother.”

While certification is not required, many doulas are certified by a national organization, such as DONA International, the Association of Labor Assistants and Childbirth Educators (ALACE), or the Childbirth and Postpartum Professional Association (CAPPA).  Certification programs typically require attendance at a weekend workshop and may also require additional reading, a written exam, proof of attendance at a certain number of births, and/or recommendations. 

Typically, women hire doulas in the second or third trimester of pregnancy.  In prenatal meetings, an expectant mother often discusses her birth preferences, her thoughts about drugs and interventions, and her fears and/or concerns. She and the doula will also explore the kinds of emotional support and comfort techniques she may find helpful.  Doulas may offer their clients further information on pregnancy and childbirth, though they do not make any medical recommendations or clinical assessments. Some doulas have additional training as childbirth educators, lactation consultants, and/or hypnotherapists.

What labor doulas offer that most medical caregivers do not is continuous support to the laboring woman.  The labor doula routinely begins her care when labor begins or whenever the woman is ready for additional support. The doula may meet the mother at home hours before she leaves for the hospital or birthing center.  A doula remains with the mother continuously throughout labor and stays until a couple of hours after the birth. The doula usually makes a postpartum home visit in the week following the birth as well.  While a labor support doula checks in with the mother in the days after a birth, a postpartum doula may be hired to help with general household chores and newborn care.

Throughout history, women have been supported by other women during childbearing.  Yet as families began living farther apart and as birth became increasingly medicalized, fewer women received this kind of support. Because they have many other responsibilities and are usually attending more than one woman, doctors, maternity nurses, and even midwives usually cannot provide continuous care. Fathers and partners offer support, but they too are experiencing the birth of their baby. Doulas have stepped in to help. Their use is becoming more popular in the United States and around the world, as is evidenced by a more than 600 percent increase in the membership of DONA International since 1992, when it was first founded.

Numerous studies show that women who get continuous care throughout labor and birth need less medication, have lower cesarean section rates, and are more satisfied with their birth experiences. ¹ 

A doula is typically hired directly by the expectant mother or parents.  However, some hospitals have introduced in-house doula programs. Under these conditions, hospitals set rules for doulas who attend births in their hospitals, thereby restricting the practice of uncertified doulas and doulas who do not want to submit to hospital policies for personal or philosophical reasons.

Even when not part of a formal program, private duty doulas’ actions are restricted by hospital policies, since doulas perform much of their work in hospitals.  As non-medical caregivers, doulas are at the bottom of the hospital’s hierarchy of power and authority.  Doulas work within these constraints, forging working relationships with hospital staff and administrators, while making it clear that they will not interfere in the practice of medicine or the delivery of medical care. Doulas must yield to medical caregivers, whether or not they agree with their approach.
   
With limited authority and professional autonomy, doulas work within the current system.  Doulas facilitate communication between the woman and her caregivers, encouraging women to advocate for themselves and to participate in informed decision making about their care. While doulas offer much-needed support to birthing women, questions remain regarding whether doulas are changing the existing system of birth for the better, or if they are perpetuating a model that is criticized by many – including some doulas – as being backwards and detrimental to the emotional and physical health of women and their babies.  

Endnotes

1. E.D. Hodnett, S. Gates, G.J. Hofmeyr, C. Sakala, "Continuous support for women during childbirth. " Cochrane Review, in The Cochrane Library, Issue 4, 2003. (Chichester, UK: John Wiley & Sons, Ltd.) Available online at http://www.update-software.com/abstracts/AB003766.htm.

Written by: Bari Meltzer Norman. Special thanks to Debra Pascali-Bonaro.
Last revised: October 2005

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