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What is a doula and why should everyone have one?

What is a doula?

The word Doula (pronounced doola) comes from the Greek word meaning a woman who serves, from the female servants who attended women through their labours and helped care for them and their children, though doulas can be any gender.

A doula wants to help the birthing person have the most satisfying and empowered time that she can during pregnancy, birth and the early days as a new mum. This type of support also helps the whole family to relax and enjoy the experience.

A doula wants to help the birthing person have the most satisfying and empowering time that they can during pregnancy, birth and in their early days as a new family. This type of support also helps the whole family to relax and enjoy the experience by taking pressure off other birth companions who may not have experience of pregnancy and labour or who feel nervous about the process or seeing their loved ones go through the process.


What does a doula do?

A doula nurtures and supports the birthing person through their pregnancy, labour, birth and if they wish, beyond. They provide continuous support through labour, no matter what decisions the birthing person makes, how they behave, or how or where they give birth (or how long it takes...). Doulas do this by providing emotional, physical, informational support and advocacy. Allowing the birthing person to maintain a sense of control, comfort and confidence.


Physical Support may include:

  • Soothing touch through the use of massage, hand holding, physical support in different positions that may aid labour

  • Creating a calm environment by dimming lights, using candles, playing gentle music, helping to guide other people present in how not to interrupt the flow of labour

  • Helping with water therapy such as aiming a shower head on to an aching muscle, applying warmth or cold, filling a birthing pool, supporting the labouring person to go to the bathroom, offering sips of drink, food, or ice chips


Emotional Support may include:

  • Making sure the birthing person feels cared for, that they have someone who believes in their strength and power even if they cannot believe in themselves in critical moments. This has been shown to help people to have more positive birth memories and experiences (Gilland, 2010b)

  • A doula can offer support, encouragement, show caring and help to provide a safe emotional space to allow feelings to be expressed. They will not judge you, they will hold you, be with you and carry you through any emotional ups and downs.

  • They can describe what they see you are feeling, echoing it back to you, offer support, help you to work through fears, anxieties, self-doubt.

  • They can help you by explaining the process of birth, what to expect, why things are happening, what you are feeling a why, all allowing you to reach a place of acceptance.

  • They can help you to explore thoughts and feelings with your birth companion, or with your care providers by acting as a buffer when emotions are strong. They will advocate for you no matter what

  • Doulas can show you evidence based information so that you can make informed decisions about what is right for you and your family, so that you can have confidence in your choices


Informational Support may include:

  • Doulas can guide you through pregnancy, labour and beyond, suggest techniques such as breathing, relaxation, movements and positions, using evidence-based information that can help your pregnancy, labour, birth and bonding and feeding relationship to progress more smoothly

  • Doulas can teach you about how birth works, what affects its progress, things that you can do to help everything go more smoothly, ways you can talk to your healthcare practitioners to build a trusting and comfortable relationship that you feel happy with.

  • They can explain medical procedures, help you to understand the benefits and risks associated with your choices, whatever you decide is best for you and your family. Doulas will do this without judgement and will happily hold a safe space for you to discuss and work through your thoughts and feelings.

  • Doulas understand labour and the path that it takes, they can reassure you when things feel different or you start to make different sounds or act differently, so you can relax, understanding why things are happening and that you are doing an amazing job.


Advocacy:

  • Doulas will support you to get the information that you need to make a decision that is considered, well informed and right for you and your family. Doula's will support you no matter what you decide, irrelevant of their own personal opinion. They will offer you information and evidence, NOT advice.

  • If you are birthing alone, your doula can help liase with medical staff to make your wishes, preferences and choices known. They can advocate for you with medical staff but also with other members of your family, helping you to maintain boundaries that you have chosen to set. Your doula will always check in with you to make sure your feelings about things are still the same as things often change in labour. Your feelings are a doula's top priority. This is your journey, we are just there to support your adventure, not to direct it.

  • A doula can help encourage you to ask questions, to verbalise your preferences, to help you to voice what support you need in having the birth experience of your choice. If your voice is dismissed or ignored, the doula will back you up, create space and time for you to ask questions and use evidence-based information.

  • If the doula notices something is about to happen that is not a part of your preferences, they will create space for dialogue so that you can feel in control e.g. 'It seems that the midwife would like to examine you, how do you feel about this? Is this something that you would like at this time? Remember you can ask them to stop at any time and they will immediately remove their hands so that you feel in control at all times. This is your body and everyone here respects that.'


A doula is there to support you in finding your power as a mother, as a father, as a family.

What does a doula NOT do?

  • Doulas are NOT medical professionals so we do not perform clinical tasks such as vaginal exams, monitoring your baby or your health

  • We do not give medical advice or diagnose conditions

  • We do not make decisions for you

  • We do not pressure you into certain choices EVER, we just help you to find evidence based information so that you can make your own informed decision, whatever feels right for you and your family. We can help you to explore your thoughts and feelings but we will not force you to decide a certain way. This is your journey, we are here to support you, whatever you decide

  • We do not take over the role of a partner, we ca support them too

  • We do not change shifts and will remain with you throughout your labour (some doulas may work with partners in case your labour is very long)


What is the evidence about doulas?

In 2017 Bohren et al, published an update Cochrane review on the use of continuous support during childbirth. They combined the results of 26 trials that had included over 15,000 people. The birthing people in these studies were randomised to receive either continuous one-to-one support during labour or 'usual care'. Overall, people who received continuous care were:

  • More likely to have spontaneous vaginal births

  • Less likely to have any pain medication

  • Less likely to have an epidural

  • Less likely to have negative feelings about childbirth

  • Less likely to have vacuum or forceps-assisted births

  • Less likely to have cesareans

  • Labours were shorter by approximately 40 minutes

  • Babies were less likely to have low Apgar scores at birth

  • There is some evidence that doula support can lower postpartum depression

  • There is NO evidence for negative consequences to continuous support in labour


The results of this study mean that if a birthing person has continuous labour support (that is, someone who never leaves their side), both mothers and babies are statistically more likely to have better outcomes!

Why a doula and not just a partner, family member or midwife?

The researchers also assessed if the type of support made a difference and did so using 6 outcomes: use of pain medication, use of pitocin (synthetic oxytocin, used to speed up/induce labour), if there was a spontaneous vaginal birth, cesarean and if the person felt they had a negative birth experience.

The best results occurred when the support was from someone who was NOT a member of staff at the hospital and who was NOT a part of their social network. Overall, with a doula present, people experienced:

  • 39% decrease in cesarean

  • 15% increase in likelihood of a spontaneous vaginal birth

  • 10% decrease in the use of any pain medication

  • 38% decrease in the risk of a low APGAR score at 5 minutes

  • 31% decrease in the risk of being dissatisfied with birth experience

  • The rate of pitocin use was not statistically significant but there was a trend towards less pitocin use with doula support compared to increased use with medical staff support


Why are doulas so effective?

  1. Doulas help to create more of a safe environment to enable natural birth physiology to work, Oxytocin to build and natural reflexes to play out. You wouldn't want to poo in the middle of a room with bright lights, monitors strapped to you, people watching and asking you questions, so why to we expect birthing people to manage to birth under these conditions? Doulas understand why and how the environment affects labour and help to make it a safer, quieter, darker, warmer, more cosy place, so your body can feel more at ease, to do what it is designed to do (Hofmeyr, Nikodem et al 1991).

  2. Doulas are a form of natural pain relief by providing continuous support, guidance, help to change positions, to breathe, to relax, etc. All helping to boost natural oxytocin and endorphin release, reducing the need for medicinal pain relief or labour augmentation through synthetic hormones (Caton, Corry et al. 2002). This is NOT just because people seeking out a doula are more likely to want a natural birth and are so motivated not to have pain medication, randomised control trials negate these factors and show that Doulas do help, statistically significantly.

  3. Attachment and support from a friendly face - Knowing and trusting that your doula has your back, will increase your oxytocin. The doula provides a secure base, diminishing stress hormones and promoting oxytocin production (Dr A Gilliand 2010a). Kirstin Uvnas Moberg states that doulas enhance oxytocin release, decreasing stress reactions, fear and anxiety and increase 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 labour feel less painful (Uvnas Mober, 2014). A doula has a clinically meaningful impact on anxiety and pain levels in first-time mothers giving birth (Ravangard et al. 2017).


How is a doula different to having your partner/a family member or friend there?

  • If you have a partner to support you in labour this is wonderful but remember:

  • They need to use the bathroom, to eat, perhaps to sleep.

  • They are also having their own emotional journey becoming a parent or perhaps a Grandparent/Aunt/Uncle, that in itself requires support.

  • They may have limited knowledge about birth, medical or hospital procedures

  • They may feel anxious when you start changing the way you behave or the noises you make

  • They may not know what to expect and get nervous during the process, bringing adrenaline into the birthing space which can slow or stop your labour


Doulas have knowledge about birth, medical procedures, they understand the birthing process and how to help it run smoothly. They can reassure and support you and any birthing companions you may have.

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 (McGrath and Kennell. 2008).

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 Cesarean rate with labour inductions was 58.8% in the group without a doula, and 12.5% in the group with a doula.

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.

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 labour 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 labour without abandoning their labouring partner (Johansson, 2015).


Fathers have said that when they had labour 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 labour without abandoning their labouring partner



The Bottom Line


Of all the ways birth outcomes could be improved, continuous labour support is one of the most important and basic needs for birthing people.


Providing labour support to birthing people is both risk-free and highly effective.


Evidence shows that continuous support can decrease the risk of Cesarean, the use of medications for pain relief, and the risk of a low five minute Apgar score.


Labour support also increases satisfaction and the chance of a spontaneous vaginal birth.


Continuous support may also shorten labour and decrease the use of Pitocin.


Although continuous support can also be offered by birth partners, midwives, nurses, or even some physicians, research has shown that with some outcomes, doulas have a stronger effect than other types of support persons. As such, doulas should be viewed by both parents and providers as a valuable, evidence-based member of the birth care team.


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