Doulas of North America Position Paper
The Doula’s Contribution to Modern Maternity Care
The birth of each baby has a long lasting impact on the physical and mental health of mother, baby and family. In the twentieth century, we have witnessed vast improvements in the safety of childbirth, and now efforts to improve psychosocial outcomes are receiving greater attention.
The importance of fostering relationships between parents and infants cannot be overemphasized, since these early relationships largely determine the future of each family, and also of society as a whole. The quality of emotional care received by the mother during labor, birth, and immediately afterwards is one vital factor that can strengthen or weaken the emotional ties between mother and child. (Ref 1-5) Furthermore, when women receive continuous emotional support and physical comfort throughout childbirth, their obstetric outcomes may improve. (Ref 6-11)Women have complex needs during childbirth. In addition to the safety of modem obstetrical care, and the love and companionship provided by their partners, women need consistent, continuous reassurance, comfort, encouragement and respect. They need individualized care based on their circumstances and preferences. The role of the doula encompasses the non-clinical aspects of care during childbirth.
This paper presents the position of DONA on the desirability of the presence of a doula at childbirth, with references to the medical and social sciences literature. It also explains the role of the doula in relation to the woman’s partner, the nurse, and medical care providers. This paper does not discuss the postpartum doula, who provides practical help, advice, and support to families in the weeks following childbirth.
Role of the Doula
In nearly every culture throughout history, women have been surrounded and cared for by other women during childbirth. (Ref 12) Artistic representations of birth throughout the world usually include at least two other women, surrounding and supporting the birthing woman. One of these women is the midwife, who is responsible for the safe passage of the mother and baby; the other woman or women are behind or beside the mother, holding and comforting her. The modern doula is a manifestation of the woman beside the mother.
Doulas are trained and experienced in childbirth, although they may or may not have given birth themselves. The doula’s role is to provide physical, emotional, and informational support to women and their partners during labor and birth. The doula offers help and advice on comfort measures such as breathing, relaxation, movement and positioning. She also assists families to gather information about the course of their labor and their options. Perhaps the most crucial role of the doula is providing continuous emotional reassurance and comfort.
Doulas specialize in non-medical skills and do not perform clinical tasks, such as vaginal exams or fetal heart rate monitoring. Doulas do not diagnose medical conditions, offer second opinions, or give medical advice. Most importantly, doulas do not make decisions for their clients; they do not project their own values and goals onto the laboring woman. (Ref 13)
The doula’s goal is to help the woman have a safe and satisfying childbirth as the woman defines it. When a doula is present, some women feel less need for pain medications, or may postpone them until later in labor; however, many women choose or need pharmacological pain relief. It is not the role of the doula to discourage the mother from her choices. The doula helps her become informed about various options, including the risks, benefits and accompanying precautions or interventions for safety. Doulas can help maximize the benefits of pain medications while minimizing their undesirable side effects. The comfort and reassurance offered by the doula are beneficial regardless of the use of pain medications.
The Doula and the Partner Work Together
The woman’s partner (the baby’s father or another loved one) plays an essential role in providing support for the woman. A doula cannot make some of the unique contributions that the partner makes, such as intimate knowledge of the woman and love for her and her child. The doula is there in addition to, not instead of, the partner. Ideally, the doula and the partner make the perfect support team for the woman, complementing each other’s strengths.
In the 1960’s, the earliest days of fathers’ involvement in childbirth, the expectation was that they would be intimately involved as advisors, coaches and decision- makers for the woman. This turned out to be an unrealistic expectation for most men because they had little prior knowledge of birth or medical procedures and little confidence or desire to ask questions of medical staff. In addition, some men felt helpless and distressed over the women’s pain and were not able to provide the constant reassurance and nurturing that women need. With a doula present, the pressure on the father is decreased and he can participate at his own comfort level. Fathers often feel relieved when they can rely on a doula for help; they enjoy the experience more. For those fathers who want to play an active support role, the doula assists and guides them in effective ways to help their loved ones in labor. Partners other than fathers (lovers, friends, family members) also appreciate the doula’s support, reassurance and assistance.
Doulas as Members of the Maternity Care Team
Each person involved in the care of the laboring woman contributes to her emotional well-being. However, doctors, nurses, and midwives are primarily responsible for the health and well-being of the mother and baby. Medical care providers must assess the condition of the mother and fetus, diagnose and treat complications as they arise, and focus on a safe delivery of the baby. These priorities rightly take precedence over the non-medical psycho-social needs of laboring women.
The doula helps ensure that these needs are met while enhancing communication and understanding between the woman or couple and the staff. Many doctors, midwives and nurses appreciate the extra attention given to their patients and the greater satisfaction expressed by women who were assisted by a doula.(Ref 14)
In the late 1970’s, when Drs. John Kennell and Marshall Klaus investigated ways to enhance maternal-infant bonding they found, almost accidentally, that introducing a doula into the labor room not only improved the bond between mother and infant, but also seemed to decrease the incidence of complications. (Ref 6,7) Since their original studies, published in 1980 and 1986, numerous scientific trials have been conducted in many countries, comparing usual care with usual care plus a doula. Table 1 summarizes the findings of these studies, confirming the value of the doula.
As can be seen in Table 1, obstetric outcomes were most improved and intervention rates most dramatically lowered by doulas in settings where the women had no loved ones present, the intervention rates were routinely high (as indicated by the data for the control groups), and the doulas were not health care professionals.
Table 1. Summary of findings of randomized controlled trials of doulas or health care professionals acting as doulas.
Key to abbreviations: n/a = not assessed; c/s = cesarean section rate; mod = moderate; NICU = neonatal intensive care unit admission;
PPD = postpartum depression; + = positive; E = experimental (supported); C = control group; O = observed group
|Author, date of study||Loved ones present?||Epidural||Oxytocin||Forceps, V/E||C/S||Apgar <7@5 min.||NICU/inc. Newborn hosp. stay||B/F @ 4-6 wks.||mod to high PPD scores @ 6 wks||+ birth experience||+ self-image|
|Studies of doulas|
|Sosa ’806||E 32||N||n/a||6%*||1%||19%*||n/a||n/a||n/a||n/a||n/a||n/a|
|Klaus ’867||E 186||N||n/a||2%*||1%||7%*||2%||2%||n/a||n/a||n/a||n/a|
|Hofmeyr ’911 & Wolman ’932||E 92||N||n/a||8%||n/a||12%||n/a||n/a||51%*||11%*||58.7%||59%*|
|Studies of trained doulas|
|Kennell ’918**||E 212||N||7.8%*||17%*||8.2%*||8%*||n/a||10.4%*||n/a||n/a||n/a||n/a|
|Kennell ’939 & ’9410||E 300||Y||67%||n/a||n/a||15%*||n/a||15.4%*||n/a||n/a||n/a||n/a|
|Gordon ’9817||E 169||Y||52.7%||61.5%||18.3%||16.6%||n/a||n/a||87.9%||n/a||43.5%*||54.6%*|
|Studies of nurses, midwives, or students acting as doulas|
|Langer ’983||E 361||N||83%||n/a||2.8%||24%||2.8%||n/a||12%*||n/a||37.6%||39%|
|Hodnett ’8918, ’8919||E 72||Y||61%*||43%||18%||17%||n/a||n/a||n/a||n/a||n/a||n/a|
|Cogan ’8820||E 20||Y||30%||43%||n/a||10%||0%||43%||n/a||n/a||n/a||n/a|
* statistically significant difference
** This study consisted of three groups, the first two of which were randomly allocated: doula-accompanied woman (E); observed women (O) (a silent observer was in the room behind a curtain); and control (C), who received usual care without a doula or an observer. Group C was added after the trial, when it became clear that the presence of a silent observer improved outcomes, possibly by influencing staff behavior or by ensuring that the women were not alone.
Two recently published abstracts reported that when women had doulas during labor, their “mother-infant affectionate interaction scores” at a home visit two months later were significantly higher than for women who did not have a doula. (Ref 1,5) Another recent randomized controlled trial reported that the cesarean rates in induced labors were reduced from 64% to 20% if a doula was present.(Ref 11)
Services and Costs
There are two basic types of doula services: independent doula practices and hospital/agency doula programs. Independent doulas are employed directly by the parents. They usually have telephone contact and at least one prenatal meeting with their clients to establish a relationship. When labor begins, the doula arrives and stays with the woman until after the birth. A postpartum meeting to process the birth is usually included in the doula’s service. Most doulas charge a flat fee for their services, and many base their fees on a sliding scale.
Some doula programs are associated with or administered by a hospital or community service agency. The doulas may be volunteers or paid employees of the hospital or agency. These programs vary widely in their design. In some, the hospital or agency contracts with an independent community-based doula group to provide the doulas. Others train and employ their own staff of doulas. Payment of the doula may come from the institution, the client, or it may be shared by the two. Some hospital/agency services are set up as on call doula services. A rotating call schedule ensures that there are one or more doulas available at all times. They meet the client for the first time and establish their relationship during labor.
Other hospital/agency doula programs make doula services available to expectant mothers or couples, who may meet and choose their doula, or have one assigned to them, along with a backup doula. They may work with their doula in much the same way that private doulas and clients work together.
There is growing third party reimbursement for labor support. Grant funding is often available, and some Medicaid-funded health agencies have contracts with doula organizations to support women in poverty and women with special needs. At present, however, most doula care is paid for directly by the client.
Training and Certification of Doulas
Doula training focuses on the emotional needs of women in labor, and non- medical physical and emotional comfort measures. Generally, training programs require some prior knowledge of childbirth, and consist of an intensive two or three day seminar, including hands-on practice of such skills as relaxation, breathing, positioning and movements to reduce pain and enhance labor progress, massage, and other comfort measures.
Certification is offered by several local, national, and international organizations. For certification, most programs require a background of work and education in the maternity field, or observation of a series of childbirth classes; a doula training course; background reading; and a written exam or essay that demonstrates understanding of the integral concepts of labor support. Positive evaluations from clients, doctors or midwives and nurses are also required.
Summary and Conclusion
In summary, the doula is emerging as a positive contribution to the care of women in labor. By attending to the women’s emotional needs, some obstetric outcomes are improved. Just as importantly, early mother-infant relationships and breastfeeding are enhanced. Women’s satisfaction with their birth experiences and even their self-esteem appears to improve when a doula has assisted them through childbirth.
Analysis of the numerous scientific trials of labor support led the prestigious scientific group, The Cochrane Collaboration’s Pregnancy and Childbirth Group in Oxford, England to state: “Given the clear benefits and no known risks associated with intrapartum support, every effort should be made to ensure that all labouring women receive support, not only from those close to them but also from specially trained caregivers. This support should include continuous presence, the provision of hands-on comfort, and encouragement.” (Ref 15)
- Hofmeyr J, Nikodem VC, Wolman WL, Chalmers BE, Kramer T. “Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding,” Br J Obstet Gynaecol, 98:756-764, 1991.
- Wolman WL, Chalmers B, Hofmeyr J. Nikodem VC. “Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study,’ Am J Obstet Gynecol, 168:1388-1393, 1993.
- Langer A, Campero L, Garcia C, Reynoso S. “Effects of Psychosocial support during labour and childbirth on breast feeding, medical interventions, and mothers’ well-being in a Mexican Public hospital: a randomised clinical trial.” Br J Obstet Gynaecol, 105:1056-1063, 1998.
- Martin S, Landry S, Steelman L, Kennell JH, McGrath S. “The effect of doula support during labor on mother-infant interaction at 2 months,” Infant Behav Devel, 21:556, 1998.
- Landry SH, McGrath SK, Kennell JH, Martin S, Steelman L, “The effects of doula support during labor on mother-infant interaction at 2 months,” Pediatric Res, 43(4):Part 11, 13 A, 1998.
- Sosa R, Kennell JH, Klaus MH, Robertson S, Urrutia J. “The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction,” N Engl J Med, 303:597-600, 1980.
- Klaus MH, Kennell JH, Robertson SS, Sosa R. “Effects of social support during parturition on maternal and infant morbidity,” Br Med J, 293:585-587, 1986.
- Kennell JH, Klaus MH, McGrath SK, Robertson S, Hinkley C. “Continuous emotional support during labor in a US hospital: a randomized controlled trial,” JAMA, 265:2197-2201, 1991.
- Kennell JH, McGrath SK “Labor support by a doula for middle-income couples; the effect on cesarean rates,” Pediatric Res, 32:12A, 1993.
- Kennell J H. “The effects of continuous emotional support for couples during labor,” Presentation at the first international conference of Doulas of North America, Seattle, WA, July 22, 1994.
- McGrath SK, Kennell JH, “Induction of labor and doula support,” Pediatric Res, 43(4):Part II, 14A, 1998.
- Ashford JI. George Engelmann and Primitive Birth. Janet Isaacs Ashford, Solana Beach, CA, 1988.
- Doulas of North America, Code of Ethics and Standards of Practice, DONA, Seattle, WA, 1992.
- Gilliland AL. “Commentary: nurses, doulas, and childbirth educators,” J Perinatal Ed, 7:18-24, 1998.
- Hodneft ED. “Support from caregivers during childbirth.” (Cochrane Review) In the Cochrane Library, Issue 2. Oxford Update Software, 1998. Updated quarterly.
- Hommel F. “Natural childbirth: nurses in private practice as monitrices,” Amer J of Nursing, 69:1446-50, 1969.
- Gordon NP, Walton D, McAdam E, Derman J, Gallitero G, Garrett L. “Effects of providing hospital-based doulas in health maintenance organization hospitals.” Obstet Gynecol, 93(3):422-426, 1999.
- Hodnett ED, Osborn RW. ‘A randomised trial of the effects of monitrice support during labor: mothers’ views two to four weeks postpartum,” Birth, 16:177-183,1989.
- Hodnett ED, Osborn RW. “Effects of continuous intrapartum professional support on childbirth outcomes,” Res Nurs Hlth, 12:289-297,1989.
- Cogan R, Spinnato JA. “Social support during premature labor: effects on labor and the newbom,” J Psychosom Obstet Gynaecol, 8:209-216,1988.
For more information about doulas, you may contact:
Doulas of North America (DONA)
Assoc. of Labor Assts. and Childbirth Educators (ALACE)
PO Box 382724, Cambridge, MA 02238, (617)441-2500
International Childbirth Education Association (ICEA)
PO Box 20048, Minneapolis, MN 55420. (800)624-4934
1200 19th St. NW, Suite 300, Washington, D.C. 20036, (202)857-1100
This paper was written by Penny Simkin and Kelli Way, and reviewed and edited by Connie Livingston, Director of Publications, and the 1998 DONA Board of Directors.
To purchase copies of this paper, contact DONA at the number above.