Birth doulas: The benefits and the tensions
When she pictured her birth, Meghan Ward wanted a support person who would be with her from start to finish. Her first choice was a midwife, but there wasn’t a midwife in the Bow Valley, Alberta region where she lives. As a compromise, she found an obstetrician for her maternity care and started looking into a doula to be with her for the duration of the birth.
Ward ended up with two doulas, one of whom was in training. The doulas met with Ward leading up to the labour and discussed positions she could try and pain relief techniques. Doulas do not provide medical care. Instead, during Ward’s labour in the hospital, “they had a very hands-on approach and did a lot of massaging,” Ward says. “They offered little mantras here and there, encouraging me to relax and breathe.”
After 28 hours of labour, Mistayah was born. In her incredibly fatigued but blissful moments with her new daughter, one of her doulas brought Ward a fruit-and-vegetable smoothie, “which is exactly what you want in that moment.” For Ward, the $900 that she spent for the support she received in pregnancy, labour and post-delivery was well worth it.
Ward is part of a growing trend. Doulas, who provide psychological support and non-medical pain relief techniques during labour, are becoming more mainstream in Canada and elsewhere. DONA International (formerly called Doulas Organization of North America), the largest association for doulas, had 4,500 members around the world in 2002. Today, there are more than 6,500 members and almost 1,000 are Canadian, according to Sunday Tortelli, president of DONA International. (Anyone can join DONA, so members include both trained doulas and those who are interested in being doulas.)
Doulas are almost always women, and there are no formal requirements for training or registration. Depending on the geographical location and how many hours a doula works, the total cost of hiring a doula can range from a few hundred dollars to more than $1,000.
Many organizations train doulas but DONA is the most recognized. To be certified by this organization, doulas must meet several standards, including attending 28 hours of courses on such topics as the stages of labour, pain relief techniques, listening skills and breastfeeding.
Doulas argue that the women they assist have better outcomes in birth. But some health professionals worry that unregulated doulas could be providing patients with misleading information that could encourage women to refuse recommended medical interventions. Others worry the growth of for-hire doulas represent access barriers to patient-centred care in the health system.
The evidence behind doula services
Several studies have examined whether or not the support of a doula improves birth outcomes, but as a whole, the evidence on doulas “is flawed” says Gareth Seaward, head of the division of Quality Improvement & Patient Safety in Obstetrics and Gynecology at Mount Sinai Hospital. For example, some studies don’t follow enough patients while others don’t account for pre-existing differences in patients who used doulas versus those that didn’t.
So far, the only clear conclusion one can make comes from a review of 22 trials that looked at the effects of continuous bedside support during labour. Depending on the trial, the support person was a nurse, doula, midwife, other lay supporter or someone in the woman’s social network. As this review shows, “one-to-one emotional support in labour does appear to be associated with less interventions and a higher potential for a vaginal birth,” says Seaward.
Seaward points out that the continuous support person during labour doesn’t need to be a doula – it could be a family member, friend, midwife or nurse. But supporters of doulas point out that in that review, the lowered rate of caesarean sections, induction and some other interventions was most pronounced when the support person wasn’t a hospital staff member nor in the woman’s social network, and was present solely to provide one-to-one supportive care.
Interestingly, Lisa Weston, who is now president of the Association of Ontario Midwives (AOM) but used to work as a doula, points out that studies suggest that low-income women may benefit the most when provided doulas.
What’s behind the growth of doulas?
Doulas are not covered by any provincial health care plan. But doula services have started to be funded by some private insurance plans, which may be contributing to their increased use. In May 2014, Sun Life Financial made doula services eligible for funding under its “health spending accounts” which includes funds for chiropractors, massage therapists and other non-medical services. Caroline Creighton, the insurance company’s media relations manager, said that only a portion of plan members have health spending accounts and what percentage of a doula’s fee is covered varies widely.
In addition to financial coverage, the doulas and medical professionals we spoke to mentioned a shift away from bedside support to more technical monitoring in hospital births as a reason women may desire a psychological and hands-on support person.
Though many hospitals have implemented a strategy of assigning one nurse to one woman in labour, “nurses have less time to spend with the patient now than they did 20 years ago,” says Doug Wilson, head of obstetrics and gynecology at Calgary’s Foothills Medical Centre. “Things are more technical, there’s more fetal monitoring to do.” Because of this, nurses may not be able to provide as much emotional support as they did in the past.
Weston says she appreciates doulas on the births she attends now as a midwife because she doesn’t feel guilty about moving away from her patient to enter the baby’s heartbeat. “I can’t necessarily be the one rubbing her back when I’m charting in the computer,” she says.
Gisela Becker, director of midwifery services for Alberta Health Services, argues, however, that midwives offer the personal and continuous care that patients are looking for when they seek out doulas – and that many, like Ward, approach doulas because they don’t have access to midwives.
Patients across Canada aren’t always able to access midwives. In Alberta, where the government has capped funding for midwives, there are only 90 practising midwives, says Becker. Even Ontario’s 740 practising midwives are unable to meet the demand for their services, says Weston. The AOM reports that 40% of women who would like a midwife are unable to access one in the province.
The fact that family doctors in Canada are delivering babies less often could also contribute to the increase in doulas. Whereas family doctors have historically followed patients from admission in the hospital until delivery, many obstetrical practices are set up as teams, so who is on shift will deliver the patient’s baby. “I didn’t know who would be delivering my baby until I was in labour,” says Ward.
Do doulas offer medical advice?
The DONA International position paper states that doulas should not offer medical advice and that doulas “do not project their own values and goals onto the labouring woman.”
But a 2010 survey of 400 doulas across Canada found that doulas do give medical advice, with 79% saying they suggest clients try non-pharmacological pain relief opportunities before an epidural is administered.
Although there is evidence that medical interventions such as epidurals can sometimes have negative effects, there are also times when they are the best option. For example, an epidural can be needed to allow a woman to relax enough so that labour can progress and in some cases, if an epidural isn’t used, a Cesarean section may become necessary, explains Seaward.
Tortelli says she personally feels that a “physiologic” or unmedicated, vaginal birth without the aid of instruments “is better for mom and baby.” She shares studies on medical interventions to aid women as they create a birth plan, but says her own preferences don’t factor into conversations.
Guelph, Ontario-based doula Dawn Humphrey also has risk and benefit conversations with pregnant women on interventions like epidurals. She says her role is “to help guard the plans mom has put in place” but also explains she can help a mother feel confident in changing those plans by ensuring that the mother understands why an intervention is being offered. To ensure informed consent, she suggests patients ask questions of the medical team, such as, “What would happen if we just continue to do things the way they are?”
One Toronto-based obstetrician who doesn’t wish to be named argues doulas usually don’t have the medical training to educate patients on the benefits and risks of medical interventions in labour. She worries that based on the information they receive from doulas, women can develop a birth plan that eschews medical intervention. In some cases, the obstetrician has seen doulas advocate for such “natural” birth choices on behalf of a labouring mother, even when medical intervention is indicated.
Doulas who encourage births without medical interventions can also negatively affect women psychologically, the unnamed obstetrician said. She recently saw a patient who was told by a doula that “her post-partum depression occurred because she had a Caesarean section, which she had for a potentially life threatening situation,” she explained. “This idea that birth is somehow all within your control is unhelpful.”
The obstetrician made clear, however, that doulas who unreasonably discourage medical intervention in birth are a minority. “Most of the time I’ve found doulas to be respectful of me as a provider,” she says. “And they can help a woman to roll with the punches if things evolve over the course of a labour.”
Communication between doulas and medical staff key to avoiding conflict
As doulas become more common, Wilson argues that doctors should have conversations with patients who have or are considering hiring doulas so they understand that doulas are not trained to provide medical advice.
Doctors and nurses can also learn from doulas, however, in how to emotionally support and inform their patients. Humphrey points out most obstetricians don’t spend time discussing the pros and cons of medical interventions with patients ahead of labour – thus, doulas may be filling a gap. (This information is provided on hospital websites and in optional hospital classes, which often charge a fee.)
And for hospital wards where continuous labour support can’t be provided by nurses or other hospital staff, doulas could be especially beneficial. Currently, however, those who may not have access to continuous support during labour and could benefit from doulas – low-income mothers – are the least able to afford doula services.