Healthy Birth Practice #3: Bring a Loved One, Friend, or Doula for Continuous Support

Abstract

All women should be allowed and encouraged to bring a loved one, friend, or doula to their birth without financial or cultural barriers. Continuous labor support offers benefits to mothers and their babies with no known harm. This article is an updated evidence-based review of the “Lamaze International Care Practices that Promote Normal Birth, Care Practice #3: Continuous Labor Support,” published in The Journal of Perinatal Education, 16(3), 2007.

One can see in art forms from generations ago that women were surrounded by other women when giving birth. Historically, women learned about childbirth from their mothers and sisters and were offered encouragement and support by them through labor. Stories and family traditions helped them to have confidence in their ability to give birth. Community midwives attended almost all births (Sosa, Kennell, Klaus, Robertson, & Urrutia, 1980). Much of that support was lost when birth moved from the home to hospital in the early 20th century. Physicians were in charge. Care for mothers in labor shifted to the nursing staff. A nurse could not always stay continuously with one woman through her labor, so she often labored alone. Birth became seen as a medical event, rather than the physical, emotional, and social occasion that it had always been.

One can see in art forms from generations ago that women were surrounded by other women when giving birth.

This article is an updated evidence-based review of the “Lamaze International Care Practices that Promote Normal Birth, Care Practice #3: Continuous Labor Support” published in The Journal of Perinatal Education, 16(3), 2007.

In the 1960s, with the advent of the natural childbirth movement, men learned about the process of birth and were with their loved ones for the birth of their child. Women no longer had to labor alone and fathers, providing their loving support, became a part of the birth team. In 1992, DONA International was founded and the name “doula” was coined. The doula’s role is to provide continuous physical, emotional, and informational support for mothers and their partners during birth and the postpartum period (Klaus, Kennell, & Klaus, 2012).

According to Listening to Mothers III, a husband or partner (77%) or the nursing staff (46%) most often provided labor support. In about one-third of the cases, support was provided by another family member or friend (37%), a doctor (31%) or, much less frequently, by a midwife (10%), a doula (trained labor assistant; 6%), or some other person (3%). For those married mothers whose partners did not provide support, 13% reported using a doula (Declercq, Sakala, Applebaum, & Herrlich, 2013, p. 16).

THE IMPORTANCE OF CONTINUOUS LABOR SUPPORT

The 2013 Cochrane Review finds that women who received continuous labor support had the following positive outcomes: more spontaneous vaginal births, fewer cesarean surgeries or instrumental vaginal births, less use of epidurals and other pain medications, slightly shorter labors, and greater satisfaction with their birth experiences. Babies of these mothers were less likely to have low Apgar scores at birth. No harms were found (Hodnett, Gates, Hofmeyr, Sakala, & Weston, 2013). They conclude that all women should have continuous support during labor and further state that the services of a person with some training, who is experienced in providing labor support, is the most beneficial. However, the baby’s father, a family member, or friend who provides continuous support increases satisfaction for the birthing woman. This review of studies included 21 trials from 16 countries, involving more than 15,000 women in a wide range of settings and circumstances.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) issued an Obstetric Care Consensus (March 2014), “Safe Prevention of the Primary Cesarean Delivery,” after their own review of the research. This report identifies labor support as a crucial factor in reducing the primary cesarean rate and notes the following about the effect of labor support:

• •“Increasing women’s access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates.”
• •“Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.”
• •“ . . . the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery.”
• •“Given that there are no associated measurable harms, this resource is probably underutilized.”

They recommend that all women receive continuous support as a way of reducing the primary cesarean rate.

When the mother has continuous support in labor, she feels safe, protected, and cared for, and she lets go of her fear. Oxytocin then rises and stress hormones lower. Fear interferes with progressive contractions and intensifies pain. Continuous emotional support is crucial for an easier, safer birth.

When the mother has continuous support in labor, she feels safe, protected, and cared for, and she lets go of her fear.

In addition, higher rates of early initiation of breastfeeding were found in an urban, multicultural setting when a doula was present (Mottl-Santiago et al., 2008).

THE ROLE OF THE BIRTH DOULA

According to Penny Simkin in her 2013 book, The Birth Partner, a birth doula “guides and supports women and their partners continuously through labor and birth” (p. 8). A doula remains with a mother throughout her labor to give continuous care through physical, informational, and emotional support. Physical support is provided for the mother as she changes positions and moves from rocking chair or ball to the bath. Sometimes, mothers want to lean on the doula during strong contractions; at other times, they want strong counterpressure to the lower back as the baby descends. Showers, massage, hot or cold packs, beverages, and other comforting measures suggested by a doula may allow the mother to relax more during and between contractions. Assisting the mother and her partner in getting information allows them to make informed decisions about their care. This advocacy improves the mother’s self-esteem and raises her sense of accomplishment, thereby improving her emotional feelings after birth and allowing her to take on the mothering role with increased confidence. The doula’s presence also allows fathers and other partners to participate in the birth in a way that is meaningful to them. If the partners wish to be more active in support, she can gently remind them about techniques they learned in Lamaze class, assist them in physically supporting the mother, and role model ways to provide emotional support to her. If partners prefer to let the doula be the primary support person, the doula can take the lead and help partners to participate in the birth to their level of comfort while ensuring that the mother’s needs are met. The doula may even give the partner a break to go to the bathroom or to get something to eat.

Another important role a doula plays is to help the new mother have the best possible memory of her birth. If the birth experience did not go as the woman had planned, the doula is there to answer questions, listen, and offer support. The doula can help a mother to work through her feelings about the birth experience, understand what happened, and, finally, assist her in integrating her birth story into her life. The role of the doula is different from that of the provider, the father, and the nurse. Doulas do not perform medical assessments such as vaginal exams or fetal heart rate monitoring. They do not diagnose medical conditions or give medical advice. They often facilitate communication between the mother and her caregivers, but they do not make decisions for their clients.

Table 1 illustrates that the doula has definite skills that others on the mother’s team aren’t able to provide. Likewise, the doctor, midwife, and nurse all have important skills that the doula cannot provide. Each member of the mother’s care team has a unique and important contribution. Working together, they insure optimal care for the birthing mother.

TABLE 1. Comparison of Providers’ Ability to Furnish Emotional Care to Laboring Women (Simkin, 2012, p. 1.2).

Components of Emotional Care	MD	Midwife	Nurse	Baby’s Father/Loved One	Trained Doula
Continuous uninterrupted presence	—	?	—	+	+
Knowledge/understanding of woman	—	?	—	+	?
Love for mother and baby	—	—	—	+	—
Knowledge/understanding of emotions and physiology of labor	?	+	+	?	+
Experience with other laboring women	+	+	+	—	+
Ability to remain calm/objective	+	+	+	—	+
Knowledge of MD, midwife, hospital policies	+	+	+	—	?
Perspective on problems/options	+	+	+	—	+
Advocacy of mother’s wishes/goals	—	+	?	+	+
Freedom from other obligations, other patients, tasks, clinical management, hospital/MD policies	—	—	—	+	+
Knowledge of comfort measures	?	+	?	?	+

Note. + = provides this component; — = does not provide this component; ? = varies.

Why don’t nurses provide the same labor support benefits as birth doulas? Ellen Hodnett asked that question in several research studies and finally in a study where nurses were trained as birth doulas and provided 1:1 care for mothers. This study was conducted in 13 U.S. and Canadian hospitals with annual cesarean surgery rates of at least 15% (Hodnett et al., 2002). The expected outcome for 6,915 participating women was that nursing care with doula training and 1:1 care would reduce the cesarean rates to levels comparable to that of women with doulas and lower than the cesarean rate of women who received standard nursing care. That didn’t happen. The cesarean rates of women cared for by the nurses in the doula-trained group were identical to the cesarean rates for the women receiving standard nursing care. The authors explain that possibly, the benefits of continuous labor support were “overpowered by the effects of birth environments characterized by high rates of routine medical interventions” (Hodnett et al., 2002, p. 1380).

LABOR SUPPORT AND MOTHER-CENTERED PHYSIOLOGIC CARE

First, the team must look to the mother/baby as the true center of birth. The mother has supported her baby’s life for months and she desires a healthy birth for her baby and herself. The mother’s ability to birth must be respected and encouraged. Her needs and wishes must be heard. She should be included in every choice and decision, and nothing should be done without her consent. If the mother is not the focus, it is not “mother centered.”

Second, the mother’s team must realize the value of continuous labor support and include the doula as an important team member in the mother’s care. When all members of the birth team respect each other’s skills and contributions, each can provide optimal care for the mother and her family. Last, the infrastructure must provide the mother with opportunities for labor starting on its own, freedom of movement, no unnecessary interventions, continuous emotional and physical support, upright or side-lying positions for birth, and nonseparation of the mother and baby following birth. Goer and Romano (2012) speak of infrastructure in this way:

Infrastructure: labor rooms with deep tubs and showers, an inviting place to walk, a lounge area for women in early labor and their families, and a kitchen with microwave and refrigerator. It would have comfortable labor room furniture that would adapt to sleeping, rocking chairs, birth balls, squatting bars, and a blanket warmer. Intrapartum units would be organized to decentralize nursing tasks so that nurses spent more time in the laboring room. Supplies would be stored in labor rooms, and monitoring and charting would be set up to be done from labor rooms as well. (Goer & Romano, 2013, p. 421)

CONCLUSION

Women deserve a community of support around them and a calm, private environment during labor and birth (Hofmeyr, Nikodem, Wolman, Chalmers, & Kramer, 1991). Family members, friends, doctors, nurses, midwives, doulas, and Lamaze educators all play a vital role in helping women to achieve safe and healthy birth outcomes. Lamaze joins the World Health Organization (Chalmers, Magiaterra, & Porter, 2001) in recognizing the value of continuous labor support in promoting safe, healthy birth. The joint statement from ACOG and SMFM marks an important shift in the guidelines for maternity care and has the potential to impact how pregnancy, labor, and birth are managed.

Continuous labor support offers benefits to mothers and their babies with no known harm. Continuous labor support is an essential component of safe, healthy care during labor and birth. All women should be allowed and encouraged to bring a loved one, friend, or doula to their birth without financial or cultural barriers.

Biography

JEANNE GREEN is codirector of The Family Way Lamaze Childbirth Educator Program, a DONA International birth doula trainer, and co-owner and author for The Family Way Publications. BARBARA HOTELLING is a birth doula and trainer who provides trainings internationally. She trains nursing students at Duke University School of Nursing where she is a clinical nurse educator.