what is a birth doula.

According to Dr. Christine Morton, author of the book Birth Ambassadors, a birth doula is a companion who supports a birthing person during labor and birth. Birth doulas are trained to provide continuous, one-on-one care, as well as information, physical support, and emotional support to birthing persons and their partners.

What do doulas do.

Their essential role is to provide continuous labor
support to the mother, no matter what decisions the mother makes or how she gives birth.

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 or counter pressure

• 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

• Reassurance

• Encouragement

• Praise

• 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?”

What doulas do not do.

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)

Why are doulas so effective.

There are several reasons why we think doulas are so effective. The first reason is the “harsh environment” theory. In most developed countries, ever since birth moved out of the home and into the hospital, laboring people are frequently submitted to institutional routines, high intervention rates, staff who are strangers, lack of privacy, bright lighting, and needles.

Most of us would have a hard time dealing with these conditions when we’re feeling our best. But people in labor have to deal with these harsh conditions when they are in a very vulnerable state. These harsh conditions may slow down a person’s labor and their self-confidence. It is thought that a doula “buffers” this harsh environment by providing continuous support and companionship which promotes the mother’s self-esteem (Hofmeyr, Nikodem et al. 1991).

A second reason that doulas are effective is because doulas are a form of pain relief in themselves (Hofmeyr, 1991). With continuous support, laboring people are less likely to request epidurals or pain medication. It is thought that there is fewer use of medications because birthing people feel less pain when a doula is present. An additional benefit to the avoidance of epidural anesthesia is that women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring (Caton, Corry et al. 2002).

This finding—that people with doulas are less likely to have an epidural—is not due to the fact that clients with doulas in these studies were more likely to want these things up front and were more motivated to achieve them. In fact, randomized trials account for these differences—this is why they are called randomized, controlled trials. The people assigned to have a doula, and those assigned to not have a doula, are randomly assigned, meaning that the same percentage in each group would have a desire for an unmedicated birth.

A third reason why doulas are effective has to do with the attachment between the birthing person and doula which can lead to an increase in oxytocin, the hormone that promotes labor contractions. This theory was proposed by Dr. Amy Gilliland in her 2010a study about effective labor support. In personal correspondence with Dr. Gilliland, she wrote, “I believe the Doula Effect is related to attachment. When the mother feels vulnerable in labor, she directs attachment behaviors to suitable figures around her, who may or may not be her attachment figures (parent, mate). When the mother directs attachment seeking behaviors to the doula, the experienced doula (25 births or more) responds in a unique manner. She is able to respond as a secure base, thereby soothing the mother’s attachment system. The accompanying diminishment in stress hormones allows for a surge in oxytocin in both the mother and the doula… theoretically, oxytocin is the hormone of attachment, and it is released during soothing touch and extended eye contact, which are habitual behaviors of birth doulas.” (Personal communication, Dr. Amy Gilliland, July 2015).

Swedish oxytocin researcher Kristin Uvnas Moberg writes that the doula enhances oxytocin release which decreases stress reactions, fear, and anxiety, and increases contraction strength and effectiveness. In addition, the calming effect of the doula’s presence increases the mother’s own natural pain coping hormones (beta-endorphins), making labor feel less painful (Uvnas Moberg, 2014).

A recent study in Iran compared first-time mothers’ anxiety and pain levels with doula support to those without doula support (Ravangard et al. 2017). They randomly assigned 150 first-time mothers to doula support or no doula support and used standard questionnaires to measure anxiety and pain levels. They found that on average, the mothers who received doula support had less anxiety and lower average pain scores during labor. The authors concluded that the doula’s presence has a clinically meaningful impact on anxiety and pain levels in first-time mothers giving birth. They recommend that all hospitals and maternity care centers in Iran provide access to doulas since having a safe and calm delivery is considered a human right.

Doulas & partners working together.

Some people think that they do not need a doula because their partner will be with them continuously throughout labor. It is true that the birth partner is an essential support person for a birthing person to have by their side. However, the birth partner will need to eat and use the bathroom at times, and they are having their own emotional journey that requires support. Also, many partners have limited knowledge about birth, medical procedures, or what goes on in a hospital, while doulas have knowledge and experience about all of these things that they can use to inform and support both the partner and birthing person. Ideally, doulas and partners can work together to make up a labor support team.

In one landmark study that evaluated the effects of doulas and fathers working together, researchers found that combining a supportive partner and a doula significantly lowered the mother’s risk of Cesarean compared to just having a supportive partner alone. In 2008, McGrath and Kennell randomly assigned 420 first-time mothers to have routine care (including a supportive partner) or care that also included a professional doula whom they met for the first time during labor. All of the women in the study were classified as having middle- to upper-class financial income levels, having supportive partners, and in the care of obstetricians. During labor, doulas provided continuous support, including encouragement, reassurance, and physical support. They helped the partner support the laboring person, and were careful not to take over the partner’s role.

The results showed a substantial improvement in outcomes for women who had both a birth partner and a doula, compared to having a birth partner alone. The Cesarean rate for these first-time mothers was 25% in the group with a partner only, and 13.4% in the group with a partner and doula. The women who had their labor medically induced experienced an even more striking decrease in the Cesarean rate with a doula—the Cesarean rate with labor inductions was 58.8% in the group without a doula, and 12.5% in the group with a doula. Also, fewer women in the doula group required an epidural (64.7%) compared to those without a doula (76%).

Research has shown that the most positive birth experiences for fathers were ones where they had continuous support by a doula or a midwife. In the McGrath and Kennell study, the women and their partners who had a doula overwhelmingly rated the support of their doula as positive—with 93% rating their experience with the doula as very positive, and 7% as positive. In other studies, fathers have said that when they had labor support from a midwife or doula, things were explained to them, their questions were answered, their labor support efforts were guided and effective, and they could take breaks from the emotional intensity of the labor without abandoning their laboring partner (Johansson, 2015).