Chances are good that if you are pregnant or have already had a baby, you have heard of the term “doula”. The leading doula organization has trained over 25,000 individuals, and has over 5,000 registered doulas attending births in the United States, and the number grows larger every year.

    In the past ten years, the doula has become a common topic of discussion among natural birthers. Articles appear in well-known newspapers like the New York Times on a regular basis, and even TV news stations have designated whole health segments for interviews with doulas and their clients. And while the number of mothers who say they clearly understand what a doula is sits around 59% of those giving birth, birth doulas are only used in about 3% of births. With all the media coverage they receive, I would think they would be more busy than that.

    The fact that 97% of births are not attended by professional birth doulas is not because of a bad reputation. To the contrary, according to a large scale survey, Listening to Mothers’ II, 100% of the women who hired a doula to attend their births were satisfied with the care they received from them, and the rating they gave doulas was higher than the rating they gave their doctors, nurses, midwives, family, and even partners.

    Labor support professionals, including doulas, have been scientifically proven to reduce the liberal use of interventions, to increase the mothers’ satisfaction of their births, reduce the rate of postpartum depression, increase the success rate of breastfeeding, enhance the bonding process between mothers and babies, and mothers and partners, and they even decrease the rate of medical complications for both mothers and babies.

    My question is, if the emotional, physical, informational, partner, and advocacy support by doulas has both been proven to be beneficial in multiple ways and has been given the highest support ratings possible by mothers, then why are not more parents choosing to hire doulas?

    I believe it is because of the concerns parents have about hiring a birth doula. There are several, very legitimate concerns that many parents have when hiring a birth doula, and if they don’t get their questions answered, they will passively decide that a birth doula is not worth their time or money.

    Since I have already described to you how a birth doula helps to create and maintain a normal birth, I will focus this article on the concerns parents have about hiring a birth doula and how to resolve them. My first suggestion being that all parents-to-be should at least call a doula in their area to address their concerns before deciding whether or not to hire one. Speaking to someone they know who has used a doula, or who is a doula, is another good way to address their concerns.

    Here are the top 10 concerns parents have about hiring a birth doula:

1) Is it worth the money? In today’s economy, money is a big concern for many people, especially those who are or will soon be responsible for feeding little mouths. If babies can be born just fine without doulas, why should you spend your extra cash on labor support? This question is of course based on your personal opinion of birth doulas, and unfortunately you will not know for sure what your opinion will be until a doula has attended your birth. The only way for you to make an informed decision, on whether or not to take this financial risk, is to learn as much as you can about doulas, and then interview doulas in your community. You may find that all the potential benefits of hiring one will convince you it is worth the money. And if you are just not able to come up with the cash, please call doulas in your area anyway. Some towns or cities have free doula programs, many individual doulas offer free or sliding-scale services to those in need, most offer payment plans or a barter option, and some hospitals offer free doulas to any patients who requests one. I have even heard of insurance companies that cover the cost of a doula. Of course you would have to call before labor starts to confirm this. Another idea is to ask your family and friends to help you pay for a doula as a baby shower gift. In conclusion, the money you spend on a birth doula could ensure you and your family with multiple long-term benefits, and if you base your answer to this concern on the experiences of women who have used a birth doula, I would hesitate to think it’s not worth the money.

2) Will a doula replace my boyfriend/husband? I would dare say that the most common reason a woman either is not interested in using a doula, or changes her mind about hiring one, is because she wants her husband or boyfriend to be the primary support person and she thinks a doula will replace him. I am here to tell you that a good doula will do just the opposite. One of the core principles doulas are taught is to involve the husband as much as they are comfortable with. Most husbands at least want to be present for the birth to encourage their wives and to witness the birth of their child. Yet many men, who are not experienced in attending births, get overwhelmed with the intensity of labor and do not know how to support their wives they way they need it. As a result, it is not unusual for a man to back off and let the nurse and epidural do all the supporting. When the doula steps into the room, most men sigh in relief  because, finally, someone is there who knows what is going on. The doula encourages not only the mother but the father, as to what is normal labor, and helps him to find specific pain relief and comfort measures that he can use to support his wife. Mothers report being more satisfied with their partner’s support, and the couples attended by a doula report increased bonding after birth, when a doula is there to support the couple through this life-changing event. Another way that the doula supports the husband is by allowing him more opportunity to create positive memories of the birth of his child. When the doula is present to support his role, he no longer feels the pressure to be a birth coach, and can instead just be there for his wife and love her, which is what women report wanting the most from their partners. And if the labor is longer or mom needs some space, her husband can leave for a short time to get a coffee, take a nap, or make phone calls, and know that his wife is being well-cared for. If the woman and her partner would like some time alone, the doula can step outside their room and “guard the door”, requesting the nurses or other staff to give the couple a few minutes alone. With a doula attending the birth, couples have more options, and tend to feel safer having someone there whom they met prior to labor and who will support the decisions they make about their care. Depending on the mother’s needs, as they change throughout labor, her doula may play an active role or remain in the background and let dad take over, but the overall atmosphere of the team is that the mother and father are the most important people in the room.

3) But my mom/friend/sister is going to be my doula. There was a time when the only birth attendants a woman had were her female relatives. The closest person she had to a “midwife” would be the woman of the town who had delivered the most babies for her friends and family. Although they did not have technology to help them handle complications, I’m sure the support women received from this network helped to keep birth as normal as possible. When women give birth in the United States today, they often ask their mother’s, or another close woman, to attend their birth, to support them emotionally through the work of labor. And while the intimacy of their relationship can be a huge benefit to the laboring woman, it is a much different dynamic than it once was. The birth knowledge of today’s mothers and grandmothers is only what they aquired through their own birthing experiences, which was usually clouded by pain medications. Female relatives and friends may have perfect intentions, but the physical and emotional support they offer is on a whole other plane from that offered by professional doulas. Doulas have attended trainings, may have attended dozens of births, has learned most everything there is to learn about normal birth, and will probably have a decent understanding of childbirth complications with their treatments. Both roles are vital to the well-being of the mother, but a female relative will not be able to offer the experience that a doula has. And, a study by Klaus, Kennell, and Klaus has shown that laboring mothers receive the greatest benefits when the doula is not related to her, although she cares greatly for her. This is because the emotional relationship the relative has with the mom-to-be cannot be objective at the same time. If you choose to bring your mother, sister, aunt, grandmother, or a friend to your birth, as long as you feel comfortable with that choice their support will probably be very helpful to you. But if you are looking for someone who has a large bag of ideas on how to cope with labor, with knowledge of how birth works and how to keep birth normal, it would be helpful to bring a doula with you as well.

4) Isn’t a doula pointless when you have a nurse-midwife? Nurse-midwives, who usually deliver babies in the hospital or in birth centers, are known for their woman-centered care. They spend more time with their patients, they encourage their patients to ask questions and express their concerns, they tend to prefer natural childbirth and are more reserved in their use of interventions. So wouldn’t a nurse-midwife offer the same support a doula would? Is a doula necessary when you have a nurse-midwife? Well, even if they did offer the same kind of support, having more than one person who has the same priorities and goals as you can be a strength in labor, especially if it turns out to be longer or more complicated than anticipated. However, doulas and nurse-midwives actually practice differently. For one, the nurse-midwife’s first priority is for the mother’s health. She is responsible to monitor labor progress and the health of the mother and unborn baby. And while she will probably be more sensitive than an obstetrician, she may very well have other patients in labor, reducing the amount of time she can spend with one woman. Her clinical duties alone will restrict the amount and quality of time she is able to provide the mother for emotional support alone. A doula’s sole responsibility is to give continuous, one-on-one care for her mental and physical comfort, something that no medical-careprovider can offer. The study I mentioned above also concluded that the benefits of labor support are greatest if the support person is not a staff member of the hospital. If the only reason you are not hiring a doula is because you will have a nurse-midwife, I strongly encourage you to learn more about the roles of both your midwife and a doula, because they are much different than each other, and you will benefit the most if you have one of each.

5) Aren’t doulas anti-epidural? The answer to this concern is not clear-cut. It really depends on the doula. If a doula is following the DONA International definition of a birth doula, she will not be anti-epidural. A doula’s job is to present women with the information that is available about her options, including the pros and cons to pain medications, and then support the woman’s decision. I’m sure many doulas have used epidurals themselves. Labor is hard work and women should not be judged for choosing to accept pain medication in labor. On the other hand, the reason doulas are usually concerned about pain medications is because they do carry some very serious risks, and a few doulas will refuse to work for a woman who thinks she will use an epidural. My personal belief is that women should reserve epidurals for very long labors (more than 24 hours hours), for induced labors (which are most painful), for complications that require bed rest during labor, and for the possibility that she will not be able to cope with the discomfort after trying all alternatives. Yet if my client decides she wants an epidural and she doesn’t fit into any of these categories, I will encourage her for making the right decision for her. One of the roles of a doula is to help the mother find non-pharmacological pain relief options, so she will probably seek to find a more natural method of helping you to relieve pain instead of jumping to the epidural first, but it doesn’t mean that she is anti-epidural. To learn whether or not the doulas in your area are against, for, or neutral on the issue of pain medications, the only thing to do is call them and ask!

6) Won’t my nurse give me emotional support? Most likely you will see your nurse much more than either your doctor or midwife, but again, the nurse could be responsible for several people, and her primary responsibility will be to monitor your baby’s and your health. In smaller hospitals, a nurse may be able to spend more time with her patients, and you may be lucky enough to be assigned to a nurse who supports natural childbirth, and has extensive knowledge about normal birth. Unfortunately, however, this is not something you can plan on because there is no way to know who is going to be on-call, or if there is any nurse available who prefers working with women who want a normal birth. If you arrive in labor and your nurse is rude and inconsiderate, you have the right to ask for a different nurse, but the best way to make sure you will have an experienced person to give you emotional and physical support is to hire a doula. And again, the same study I mentioned about labor support referred to nurses as well: the women who receive the greatest benefits of labor support (eg. fewer medical complications) are attended by a doula who is not a nurse working for the hospital. Most people who choose to be obstetrical nurses do so because they care for childbearing women and love to witness life coming into the world, but that doesn’t mean that you will be assigned a nurse who will give you the continuous, one-on-one emotional and physical support that you need.

7) I just don’t want an extra stranger at my birth. Birth is one of the few times in a woman’s life when she is extremely vulnerable and is unable to truly protect herself. In order to give birth, a woman needs to shut down the thinking side of her brain and go into what has been called, “Laborland”. Birth often or always involves the following: nudity, gas, poop and pee, amniotic fluid, multiple vaginal exams (sometimes by several different people), and not knowing who is going to come in the door next. Knowing who will attend your birth is probably a very important issue to you, as it should be. However, if you are planning a hospital birth, the only person you can count on being there, is your doula. If your doctor or midwife works in a practice with other careproviders, it is luck of the draw who will be on-call when you go into labor, and as I said before, you won’t know who your nurse is either. You could easily end up with complete strangers attending your birth, but if you hire a doula, she won’t be a stranger to you. Most doulas meet with their clients at least twice prior to birth, sometimes several times, so you can get to know each other, and so the doula can learn what is most important to you about your upcoming birth. You will talk on the phone, converse online, and she may even offer childbirth preparation classes for you to attend. As a doula, it is important to me that I develop a relationship with my clients prior to their birth, and except for two very fast labors, I have not missed one birth. Doulas focus on relationship because it is essential if the mother is going to feel comfortable having her there for her birth, and because the doula will know how to help her best if she has learned about the mother’s personal needs. By the time labor starts, your doula will be anything but a stranger.

8 ) I don’t need a birth doula if I’m having a home birth, right? Doulas are known for advocating a woman’s wishes to the hospital staff, and for trying to prevent uneccessary interventions, so if a woman chooses to give birth at home with a midwife who is all about whole-body care, is it worth hiring a doula? I would argue that if a doula doesn’t have to spend time advocating a mother’s wishes to her careproviders, she can spend more of her time on what matters most: supporting the mother. And while staying at home makes it much easier to keep birth normal, labor is still very hard work and the mother, father, and even the midwife will benefit from having a doula present. Because there are no shift changes, potentially long labors can wear out the only birth team a mother has at home, and therefore, midwives will appreciate the support of a good doula, who will enhance their own role and make it easier for the midwife to to do what she does best: to facilitate a normal birth experience. Just as a doula is not the same thing as a nurse-midwife, doulas are not the same thing as a home birth midwife. Instead they can work together to help make your hopes for birth comes true.  

9) I’m planning a c-section, so why should I hire a doula if I won’t be laboring? One in three women give birth by cesarean section, some planned, some emergency, and some because the doctor thinks labor will go on too long. When a woman is attended by a doula and her labor ends with surgery, the doula’s role does not end. She helps the mother to come to terms with the situation, talks to her about the pros and cons of the decision, helps to calm her fears, explains how this will affect immediate postpartum care, and allows her time (if is is given by the staff) to process the change of plans before she is wheeled into the OR. If the father or other significant other does not or cannot be present for the delivery, the doula can go into the OR with the mother to support her through surgery. After the birth, the doula will meet the mother in the recovery room, praise her for her work, answer questions, take pictures if desired by the mother, and help to get her started with breastfeeding if she wishes to. If the c-section is planned, the doula will support her much the same way, by helping her to learn about cesareans ahead of time and how to make it a positive experience, encourage and reassure her, help her to get settled into her hospital room before surgery, attend the birth if the father can’t be there, and meet her in recovery. Although doulas are known for their expertise in pain-relief techniques during labor, their experience with birth can be a very reassuring asset to a woman who is nervous about her upcoming cesarean birth.

10) I’ve heard doctors don’t like doulas because they get in the way. It is true that some doctors do not like to have doulas attend their patient’s births, but that is only because he doesn’t understand the role of a doula, he has had a bad experience with a doula, or he has heard stories from other doctors. Sometimes doulas are more “natural childbirth activisits” than they are doulas, or perhaps they are a mix of both. If the doula is vocal to the nurse, doctor, or midwife and challenges their knowledge or decision-making, the careprovider will feel threatened and may ask the doula to leave the hospital right away. Most of the time that is not what happens, and a doula will politely ask questions, ask about alternatives, but most importantly they will encourage the mother and father to find their own voice and talk to their doctor about what is important to them. If you have met with your doula prior to birth, you will know if your doula is the type who will challenge the doctor, or if she is more concerned about being with you through till the end. Some women prefer a doula who will stick up for them, and some prefer their doula let them do their own talking. There is no wrong answer, but it would be a good idea to at least talk about the subject with your careprovider ahead of time. A lot of doctors and midwives really like to work with doulas, and they may even know the names of a few reputable ones in your area. If you are not satisfied with your careprovider’s answer, it may be a sign that you are not compatible with each other and maybe it is time to start interviewing other doctors or midwives. In the end, please don’t let negative media attention taint your view of doulas. Just like there are “bad doctors”, “bad nurses”, or “bad midwives”, there are some doulas out there who should probably be looking for a different field. Yet most doulas’ first priority is to help keep things as smooth as possible, including the relationship between you and your doctor.

I hope I have helped to answer your questions about doulas, and that you now feel more comfortable hiring a doula. The best way to know whether you have found the right one or not is to meet at least a couple times with her before labor, ask lots of questions about how she practices and her experience. She may also have email addresses or phone numbers for past clients who are willing to give feedback about her care. Here are a couple good websites to check out that have some questions you can ask your doula.

http://pregnancychildbirth.suite101.com/article.cfm/top_ten_questions_to_ask_a_doula  http://birthrootsdoulas.com/questions-for-birth-doula.php

Here is a short documentary on doulas that you may also find interesting.

 If you have any other questions about doulas, please leave a comment below.