Continuous labor support – doulas and partners
Continuous support in labor is provided by doulas, women specially trained to assist women during childbirth. The presence of doula improves the feeling of wellbeing among laboring women, helps coping with childbirth and gives the feeling of being in control. The effect of continuous support in labor on pain is modest.
Drugs are not the only way to reduce pain and suffering during childbirth. Simple compassion goes a long way, and women in labor have been receiving support of close friends or relatives since the beginning of times. Traditionally, such support has been provided by other females. As childbirth move into hospitals it became the domain of medical workers, doctors, midwives and nurses, and support became the job of husbands or fathers of the woman in labor. Unfortunately most men know very little about childbirth – definitely have never experienced it themselves – and though there is no lack of compassion from husbands, they cannot possibly be as understanding as other women when it comes to delivering a child.
To make woman’s experience in labor less stressful, birth support was re-introduced in the hospitals in the seventies, and in the mid-eighties first research studies were published. Because of the early positive results more research was conducted, and today continuous support is part of the standard care of women giving birth. This is done by specially trained females called doulas.
The word doula comes from Greek and in its original meaning refers to the woman of service. Doulas may provide support to the woman before, during and after birth. In most countries including USA, Canada and Australia it is not the requirement for the doulas to be certified or registered with the medical governing bodies. There are numerous colleges that provide training for persons wishing to become doulas, and subjects of the course include basic physiology of childbirth, first aid, emotional support and education in other areas of health that may be helpful when giving support to laboring women.
Doulas are not directly involved in making a diagnosis or treating complications. Instead, their scope of practice includes the following.
- Physical comforting: touch and massage, stroking, rubbing the back, helping with positioning, bathing, grooming, applying warmth or cold.
- Emotional support: continuous presence, reassurance, encouragement.
- Guidance and emotional support for the woman’s partner. That’s right, husbands and other members of the woman’s family also need support. Being unable to help the loved one’s in pain and suffering is very distressing, especially with no previous experience with the process of childbirth.
- Information: non-medical advice, explaining what to anticipate, explanations of procedures.
- Finally, helping communication between the woman and staff and to assist in making informed choices.
One of the (many) colleges I found of the Net offered a course for those wishing to become a doula during which the students would attend six Doula training days, Women’s Mysteries Five Day Retreat, complete Spiritual Midwifery course, attend Childbirth Preparation Classes with other women and have Bellies and Babies Sessions, one hundred and seventy hours in total. As you can see, being a doula is not so much about formal education but rather about compassion and the desire and the ability to help others with childbirth.
Does having a doula around during labor makes a difference? There are claims that there are. According to some sources women with support have shorter labor, use less pain medication, less likely to have caesarean section and instrumental delivery – the use of forceps. It is also claimed that babies born during supported labor have lower risk of foetal distress and lower risk of serious complications. Finally, there are also claims that greater proportion of women supported by doula are breastfeeding at six weeks after delivery, had greater self-esteem, less depression and higher regard for their babies.
As always, the devil is in the details. After reviewing available publications, the review of the effects of continuous support in labor published in the Cochrane Database and last updated in 2007 established that doula support did the following.
- Reduced the need for regional analgesia (epidural and paracervical blocks) by 10%
- Reduced requests for any pain relief, including epidurals, by 13%
- The number of women who after delivery said they had severe pain during their labor decreased by 3%
- Increased the rate of spontaneous vaginal birth by 8%
- Reduced the need for forceps or vacuum by 11%
- Decreased caesarean section rate by 10%
- The number of babies who had low Apgar scores five minutes after birth decreased by 19%
- The number of women who felt they had low control during labor decreased by 21%
- The number of women who had difficulty coping with labor decreased by 45%
- The number of women who continued breastfeeding at 1-2 months after labor increased by 6%.
The numbers above confirm what you would normally expect from the presence of a compassionate and caring person: it does make childbirth easier. More women felt in control and were able to cope with childbirth.
However, the interpretation of the results becomes more complicated when other factors are taken into account. For instance, the use of additional pain relief and epidurals was considerably higher where support was provided by the members of the staff working in the institution, and lower where doulas were outsiders. Another example: the effect of continuous support on satisfaction with childbirth was considerably stronger in institutions where epidural analgesia was not routinely available.
Similarly, the reduction in caesarean sections, even small, should be considered with caution. As discussed elsewhere on this site, the decision to proceed with the caesarean is a complex one and depends on the multitude of factors. It is therefore likely that the finding that the presence of doulas reduces the need of operative delivery is coincidental. At least more research is needed in order to make definite conclusions.
Overall, continuous support in labor is useful. However its effect on labor pain is modest at best: the use of additional pain relief was reduced by ten percent. In other words one in ten women benefited. While I do not doubt the sincere intentions of doulas, I suspect that their presence may affect women in various ways. In some instances they may have talked the women out of having epidurals rather than have reduced the severity of pain. This is indicated by the fact that while continuous support resulted in about ten percent reduction in requests for pain relief, the reduction in the number of those who experienced severe labor pain was considerably less: only three percent.
1. Hodnett ED, Gates S, Hofmeyr G J, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.