The Many Benefits of Birth Doula Support, Part 2 by Kelly Martin

The Many Benefits of Birth Doula Support

The experience of childbirth reverberates throughout a mother’s lifetime.  The constantly changing sweep of personal, family, and community history are intertwined with the cultural and psychosocial meaning of birth — for the mother, the child, and the family.  In this way, childbirth is seen as one of the critical life events that can either connect a family – or disconnect a family.  It is society’s responsibility not to allow the moment of birth to shrink into an invisible, unacknowledged episode of medical intervention.  As a society, it is imperative that to rally for the right to birth choice and support. 

            A great deal of research has been conducted that addresses the positive effects that supportive caregivers, such as doulas and labor assistants, can have on outcomes in women’s childbirth experiences.  A doula is an advocate for a woman in labor.  Drs. John Kennell and Marshall Klaus used the Greek word "doulos" (meaning a willing servant without the need for bondage), to describe a trained professional that recognizes birth as a key life experience (Klaus, Kennell, & Klaus, 1993).  A doula is described as a woman experienced in childbirth who provides continuous physical, emotional and informational support to the mother during pregnancy, during labor, and just after childbirth (Klaus, Kennell & Klaus, 1993).  Dr. Dana Raphael, an anthropologist, in her book published in 1973 called "The Tender Gift:  Breastfeeding," may have been the first person to publish the title "doula" to identify a female who gives psychological encouragement to a postnatal woman.   A doula does not perform clinical tasks, or provide medical care.  Instead she focuses on emotional and social support.  She may provide education, logistical planning, and social support.

The use of a doula is an innovative option to address complex disparities in health care during pregnancy, labor and postpartum.  In the broadest sense of role, a doula is a community health worker (or paraprofessional) who provides skilled and intimate continuity of care throughout the childbearing year.  

A great deal of research has been conducted regarding the impact that supportive caregivers such as doulas and labor assistants can have on women’s birthing experiences.  A doula’s role encompasses all non-clinical aspects of care.  DONA is a certifying doula agency in the United States that trains women to be practicing doulas.  Their core standard of ethic is that a doula can provide emotional, mental, and physical support to a mother – but she is unable to perform anything "medical."  She doesn’t take blood pressure, or do cervical checks for dilation, or provided I.V.’s or injections.  She simply "mothers the mother."

More than fourteen randomized clinical trials have been documented in a number of countries that have shown that continuous social, physical, and emotional support can help control pain, reduce the length of labor, and decrease the use of cesarean sections and other invasive procedures (Scott, Berkowitz, & Klaus, 1999; Hodnett, 2002). Other positive effects of support involve increased psychosocial benefits such as healthcare system cost savings, reduced resource utilization, and increased patient satisfaction.  Labor support has also been correlated with improved breastfeeding rates (DONA International, 2005; Hodnett, Osborn, 1989; Hodnett, 2002a), and a decrease in postpartum depression (Beck, 2004b; Creedy, Shochet, Horsfall, 2000; Czarnocka, Slade, 2000).

Two hallmark studies were conducted in Guatemala, the first was a randomized control study by Sosa et al. (1980), which studied the amount of time women labored with a supportive birth companion, in comparison to women who did not.  This study found that labors were significantly shorter labors for the women with support (8.8 versus 9.3 hours).  The second randomized control study by Klaus et. al. (1986) found that supported women had a reduced incidence of cesarean section birth, had fewer perinatal complications, and had a decrease in oxytocin induction/augmentation (Madi et. al., 1999). 

Several studies were conducted in North America to determine if these findings could be replicated.  The studies all found the same positive outcomes with continuous doula care. 

Study 1

Pascoe (1993) studied nulliparous women who were referred to two community birth companion programs in Michigan from 1983 to 1987.  Training was provided to the volunteer doulas (i.e., birth companions).  Length of labor was shortened in the group who received continuous doula support during labor.

Study 2

Gordon et al (1999) randomly assigned laboring women who received care from a health maintenance organization in northern California, to receive care from either a trained doula providing continuous labor support, or to a usual care group.  A decrease in epidural anesthesia use was reported from the group of women who were supported by a trained doula.

Study 3

Hodnett and Osborn (1989) studied the effects of continuous labor support in a North American hospital.  Continuous labor support was provided by professional self-employed lay midwives or midwives in training who had previous experience providing continuous intrapartum support to a minimum of twenty laboring women.  Although continuous labor support did not have an effect on the length of labor, or the cesarean rate, those participants who received continuous labor support were less likely to need pain relief, and to have episiotomies compared to those who received traditional nursing support.

Study 4

Campero et. al., 1998 study examined women’s overall experiences with doula support.  This qualitative study investigated the experiences of childbearing women who received doula support during the perinatal period.  The doulas provided the same support as in the previous studies, and provided further evidence of the importance of forming trusting relationships with caregivers (Hodnett, 2002), and the value of being prepared for birth (Zwelling, 1996).  The evidence provided by these trials suggests that lay labor support would be an invaluable addition to modern maternity care in the childbirth and the postpartum period.  Despite the health and cost-effectiveness of doula care, one national survey indicated that only about 8% of women have used doulas at their births (Sakala, Declercq & Corry, 2002).  It is believed, however that this number has increased substantially in the last decade (Lantz et al, 2005). 

The range of doula support varies, as does who the doulas are themselves.   The Association of Labor Assistants and Childbirth Educators (ALACE), Birth Works, Childbirth and Postpartum Professional Association (CAPPA), Doulas of North America (DONA), and the International Childbirth Education Association (ICEA) produced a survey recently to examine who doulas are.  Current members who were residents of the United States and had started, or completed doula/labor assistant certification were surveyed.  A random sample of 1,000 doulas was selected, including 700 certified doulas and 300 with certification in progress.  Over 57% of the respondents were certified through DONA.  The respondents had the following sociodemographic profile:  94% reported their ethnicity as white, 3% African American, 2% Hispanic, and 1% other ethnic groups.  The average age was 40.3, with a range from 20 to 71 years old.  The majority of doulas were currently married (82%) and had given birth at least once (88%).  In terms of education, almost 49% reported that they had a college degree or more, with 20% credentialed as a nurse or midwife.  In addition, one out of three respondents reported prior training in some type of childbirth preparation instruction.  The average income in 2002 from doula work was $3,645 amount certified doulas with almost half reporting that they made less than $1,000.  The research revealed that doulas represent individuals from a range of academic and professional backgrounds united in their desire to support and enhance the childbirth experience of women.  The primary characteristic that differentiates the professional doula from other support people is the technique of continuous care.  The professional doula is committed to being present with the laboring woman 100% of the time.  The research revealed that doulas represent individuals from a wide range of academic and professional backgrounds whose commonality was in their desire to support and empower women birthing.  The primary characteristic that differentiates the professional doula from other medical support professionals is simply that they have the ability to give continuous care.  A doula is committed to being present with a laboring woman 100% of the time (Hodnett, 1996). 

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