What can you tell me about doulas?
It is common knowledge, and soundly supported by multiple studies, that doulas improve birth outcomes and, equally importantly, women's *feelings* about those birth outcomes.
According to evidencebasedbirth.com:
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.
A doula can provide labor support via the four pillars of labor support. In the textbook Best Practices in Midwifery, the author describes three pillars of labor support as emotional support, physical support, and advocacy. In the book Optimal Care in Childbirth, informational support is also listed as a pillar of support.
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
- 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 labor
- 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 labor (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)
What is the evidence on doulas?
In 2017, Bohren et al. published an updated Cochrane review on the use of continuous support for women during childbirth. They combined the results of 26 trials that included more than 15,000 people. The birthing people in these studies were randomized to either receive continuous, one-on-one support during labor or “usual care.” The Cochrane reviewers stated that the overall quality of the evidence is low-quality, according to the GRADE systems for assessing evidence. In the GRADE system, the quality of evidence for each outcome is graded as one of four levels: high, moderate, low, or very low. A rating of high would be considered great evidence, where the authors are very confident that the true effect of doulas is very close to the effect seen in the study results. On the other hand, a rating of very low means that they have very little confidence in the findings, and that the true effect of doulas is likely to be very different than what was seen in the study results. The middle ratings aren’t great, but they aren’t weak either. Since it is not possible to blind participants or care providers to continuous labor support, the quality of the evidence for doulas received a lower grade.
Continuous support was provided either by a member of the hospital staff, such as a midwife or nurse (nine studies), women who were not part of the birthing person’s social network and not part of hospital staff (doula, eight studies; childbirth educators, one study, retired nurses, one study), or a companion from the birthing person’s social network such as a female relative or the woman’s partner (seven studies). In 15 studies, the husband/partner was not allowed to be present at birth, and so continuous support was compared to no support at all. In all the other 11 studies, the husband or partner was allowed to be present in addition to the person providing continuous labor support.
Overall, people who received continuous support were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and Cesareans. In addition, their labors were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth. There is a smaller amount of evidence that doula support in labor can lower postpartum depression in mothers. There is no evidence for negative consequences to continuous labor support.
The results of this study mean that if a birthing person has continuous labor support (that is, someone who never leaves their side), both mothers and babies are statistically more likely to have better outcomes.