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.

One can see in works of art across cultures and throughout time that women have been surrounded by other women during birth. Historically, women learned about childbirth from their mothers, sisters, and other women. Stories and family traditions helped them to have confidence in their ability to give birth. Family members and women friends offered encouragement and support to the laboring woman. Community midwives attended almost all births. Much of that support was lost when birth moved from the home to hospital in the early 20th century. Physicians were in charge. Neither family nor friends were allowed to be with a woman during labor in a hospital, so her care shifted to the nursing staff. A nurse's responsibilities were often divided among other patients, so women usually labored alone. Birth came to be seen as a medical event in the hospital, rather than the supported physical and emotional occasion that it had always been at home (Sosa, Kennell, Klaus, Robertson, & Urrutia, 1980).

In the 1960s, a movement began to promote education for expectant parents. Men as well as women learned about the process of labor and birth, and were taught skills for coping with pain. This allowed men to offerlabor support and to be present for the birth of their child. Women no longer had to labor alone, and fathers became a part of the birth team. The name doula (derived from the Greek word) was first coined by anthropologist Dr. Dana Raphael to refer to women who offered breastfeeding support to new mothers, and later to female caregivers serving women before and during labor and birth. DONA International, founded in 1992, adopted this term to describe the caregivers to whom they offer doula education and certification. The term and the profession have spread around the world. The presence of a doula may allow partners who prefer a less active role to be more comfortable simply observing the birth. 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).

The Listening to Mothers Survey III looked at who provided labor support for women in the United States (2013). 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%). Only 6% of the women surveyed had a doula; however, 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 Cochrane Review on labor support (2017) found that women who received continuous labor support had the following positive outcomes:

• More spontaneous vaginal births

• Slightly shorter duration of labor

• Fewer cesarean surgeries or instrumental vaginal births

• Decreased use of epidurals and other pain medications

• Greater satisfaction with their birth experiences

Babies of these mothers were less likely to have low 5-minute Apgar scores. No harms were found. This review of studies included 26 trials, from 17 countries, involving 15,858 women in a wide range of settings and circumstances. The Cochrane reviewers concluded that all women should have continuous support during labor, and that the services of a person with some training, and 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. “Historically, women have generally been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has often become the exception rather than the routine” (Bohren, Hofmeyr, Sakala, Fukuzawa, & Cuthbert, 2017).

Intrapartum care for a positive childbirth experience, published by the World Health Organization (WHO, 2018), states: “Respectful maternity care—which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth—is recommended.” The new WHO guidelines include 56 evidence-based recommendations on what care is needed throughout labor and immediately after for the woman and her baby. These include having a companion of choice during labor and childbirth; ensuring respectful care and good communication between women and health providers; maintaining privacy and confidentiality; and allowing women to make decisions about their pain management, labor and birth positions, and natural urge to push, among others.

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, so 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.

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).

Findings from a study by DONA International (Everson, et al. 2018) indicate the potential for doula care as a best practice to improve health outcomes and promote healthy, safe, and physiologic birth among adolescent childbearing women. A national sample of doula-supported adolescent births (n = 1,892, birth years 2000–2013) in the United States showed that childbearing adolescents and their babies experienced improved health outcomes and lower rates of intervention relative to national statistics for adolescent births. Women of color comprised over half the sample. These results strengthen the case for doulas as a perinatal care strategy for improving maternal and infant health outcomes and decreasing inequities among childbearing adolescents.

The Role of the Birth Doula

According to Penny Simkin in her book, The Birth Partner (Simkin & Rohs, 2018), the doula is an experienced guide and support person to the pregnant person or expectant couple (p. 21). 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 counter pressure 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 (Simkin, 2002). 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, the doula can gently remind them about techniques they learned in childbirth 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 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, to listen, and to offer support. The doula can help a mother work through her feelings about the birth experience, understand what happened, and finally, assist her in integrating her birth story into her life.

Each member of the mother's care team has an important contribution. Ideally all should 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 respect and encourage the mother's ability to birth, each can provide optimal care for the mother and her family. The doula has skills and opportunities that others on the mother's birth team may not be able to provide, such as her knowledge of comfort measures and understanding of the mother's goals for her birth. The doula can offer her continuous presence without obligations to others and can be the mother's advocate while offering her perspective on options. 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. The physician, midwife, and nurse have knowledge and experience through their medical training that a doula and birth partner most often do not have. The mother's loved one attending the birth can offer comfort and emotional support through knowledge and understanding of the woman, love for her and the baby, and by being a continuous presence through labor.

A study by Ellen Hodnett found that continuous labor support by nurses who were trained as birth doulas and assigned one-on-one care for laboring women did not result in the same improved outcomes as occur with labor support by a birth doula. This study occurred in 13 U.S. and Canadian hospitals with annual cesarean birth rates of at least 15% (Hodnett et al., 2002, p. 1373). The expected outcome for 6,915 participating women was that care by nurses having had doula training and giving one-on-one care would reduce the cesarean rates to levels comparable to that of women with birth doulas and lower than the cesarean rate for 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 the benefits of continuous labor support were possibly “overpowered by the effects of birth environments characterized by high rates of routine medical interventions” (Hodnett et al., 2002, p. 1380). It has also been found that labor nurses' own birth experiences affect their attitudes toward giving support to women in labor (Aschenbrenner, Hanson, Johnson, & Kelber, 2016). Doulas, on the other hand, enter their profession because of a desire to offer labor support to others.

Racial Disparity: Doulas Can Help Make a Difference

The WHO recommends that doulas attend all births globally. The WHO has developed a Safe Birth Checklist in which doula support is included (December 2015). This checklist has been developed to support the birth of essential maternal and perinatal care practices worldwide. It was developed following a rigorous methodology and tested for usability in ten countries across Africa and Asia.

As part of an effort to reduce maternal mortality and racial disparities in health outcomes in the State of New York, Governor Andrew Cuomo announced a series of initiatives aimed at addressing a disturbingly high rate of maternal mortality among Black women. This included a pilot program to expand Medicaid coverage for doulas in New York (Ferre-Sadurni, 2018). Based on associations between doula care and preterm and cesarean birth, coverage reimbursement for doula services would likely be cost saving or cost-effective for state Medicaid programs (Kozhimannil et al., 2016).

Chronic stress associated with being a minority, particularly being African American, increases the risk of delivering a premature, low birth weight baby. Researchers are looking at chronic stress—the stress caused by living day in and day out with discrimination. Stress hormones are part of the intricate chemistry of pregnancy. When those hormones reach a certain level, they may help trigger labor, which could lead to premature delivery (Corwin, 2013). An excellent documentary on this subject is titled, Unnatural Causes: When the bough breaks. It has been suggested that culturally competent doula services can help reduce stress during the perinatal period. Having a doula can reduce the risk of a cesarean, medical intervention, aid in shorter labors, increase breastfeeding in the first hour after birth, and create a feeling of satisfaction with the birth experience by both parents. Various organizations are working to increase the number of women of color who are doulas and midwives. The Greensboro, North Carolina, YWCA Healthy Beginnings Doula Program is focused on reducing adverse birth outcomes by offering psychosocial, perinatal support, and wellness programming, including doula support for women at risk for adverse birth outcomes because of low income and racial disparities. The Program helps these women access appropriate positive support through the use of doulas who are available to a woman months before going into labor. These doulas are often from the same communities as the women who receive their services. The results of a study on this Program showed that socially disadvantaged women can improve their birth outcomes if given a system of psychosocial and health support (Gruber, Cupito, & Dobson, 2013).

At both Johns Hopkins and Duke University Schools of Nursing, students are given the opportunity to attend birth doula training to learn support of prenatal, intrapartum, and postpartum women and their families. As part of the training, they learn to participate as team members providing continuous physical and emotional support to women in the perinatal period (O'Brien 2018). Working with Community Health faculty at Duke, students have the opportunity to provide doula services for the Church World Services Immigration and Refugee program, and at Hopkins many of the students have been Peace Corps volunteers who served in the mothers' countries of origin.

CONCLUSION

All women deserve a community of support around them and a calm, private environment during labor and birth (Hofmeyr, Nikodem, Wolma, Chalmers, & Kramer, 1991). Family members, friends, doctors, nurses, midwives, doulas, and Lamaze educators all play an important role in helping to achieve safe and healthy birth outcomes. Lamaze International joins the WHO in recognizing the value of continuous labor support in promoting safe, healthy birth. The joint statement from ACOG and SMFM 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. It is a desirable 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.

Biographies

JEANNE GREEN is coauthor of Prepared Childbirth—The Family Way, Prepared Childbirth—The Educator's Guide, and the 2012 and 2015 editions of The Lamaze Toolkit. She is codirector of The Family Way Lamaze Childbirth Educator Program and a DONA International birth doula trainer.

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.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.