September 07, 2002

More on doulas

It is very good to see the debate/discussion about doulas, both in response to my Diary entry and also on the ozmidwifery list. This is an important issue that needs wide consideration and I am happy to kick that off, and in this Diary entry, to keep it going, through raising some new points.

Let’s consider some of the claimed benefits for doulas. It has been stated that the presence of a doula can improve birth outcomes by lowering the need for interventions, even to the extend of reducing the need for a caesarean by 60% (this statement appears in Suzanne Arms’ video Giving Birth Challenges and Choices”). However, it is well proven that it is the attitudes, practices and philosophy of the primary care giver that shape the birth experience for a woman and it is this care giver who has the greatest influence on the outcome of the birth. It is hard to see how the presence of a doula could make any difference to the outcome of the birth, given that they have no say in the management of the case. If research can show that the presence of the doula causes the care giver to act differently, then it may be possible to change the course of management, but this seems a stretch to me.

Again, let me go back to the US scene. I have just read in my copy of Birth - Issues in Perinatal Care that the rate for caesarean sections in the US, having been 24.7 % in 1988, then dropping to 20.8% in 1995, has risen again and now stands at 24.4% in 2001. VBAC rates have dropped from 36.5% in 2000 to 16.5% in 2001 (a drop of a massive 20%). I can’t imagine the presence of a doula making much of an inroad in this climate. In countries with much higher rates of caesareans (Brazil and South Africa, for example) all that a doula can hope to do is to make the wait until the caesar occurs a little more humane and comfortable. While this is an important and valuable goal in itself, it will not contribute much to improving the final outcomes.

In the developed world, where midwives already exist in numbers, the way to get better outcomes is to strengthen their role and provide opportunities for them within the system (this is where NMAP comes in). Doulas may be useful to supplement the role of the midwife and to replace absent friends or family but they are perhaps best described as an “extra” at a birth, not an essential member of the “team”. I prefer to put my energy into energising and uplifting the resources we have - the midwives - rather than work on an alternative that might actually (if unintentionally) undermine midwifery. I also believe that almost every woman could find a close friend, if not a family member, to be with her during birth, and that we should encourage this every time, as a way of strengthening family and community bonds.

In the developing world, there is an added risk that some women will be lucky to get a companion and other will miss out, because it would be difficult to provide enough doulas to meet every woman’s needs. Therefore, if change is to occur for the greatest benefit to all, then the system has to change from the top, that is, the doctors and nurses that are already in place must be encouraged to change their views, attitudes and practices. This is a very tall order, and will take a lot of time, good will and re-education, but it has the greatest potential for doing the greatest good. Perhaps that’s where the energies and resources should be directed, rather than on some new “fad” as the doula approach may come to be seen.

Another issue of importance in developing countries, is that women acting as doulas will need to be paid for their work. This is an important way of giving many woman an income that is much needed, but even that carries risks. People who are paid have a vested interest in keeping themselves in work and are not necessarily interested in political agendas for changing the system that feeds them.

The research into the benefits of doulas has mostly been carried out in developing countries and for that reason perhaps much of the findings are relevant and applicable to those maternity care systems. However, I haven’t seen much research carried out in US hospitals, for example, that shows that the presence of a doula improved birth outcomes and lowered intervention rates. Yet the claims being made in western countries for the usefulness of doulas are being based on results obtained from studies carried out in very different circumstances. Research from the dev eloping world is being co-opted to make a case for a “commercial” venture in the US.

Doulas may, in the long run, get dispirited and burnt out if they go into this work thinking they will be able to change the system and make birth better for women. They need to be very clear about their own goals and expectations for this work, and so do all the health professionals that they encounter. At the end of the day, it may be the money to be made as a doula that enables them to justify their work in their own mind.

There are other points to make about this issue (as I say, it is a weighty one) but I will save them for another day, and see what people think of these ideas first. I am sure you’ll have an opinion on what I’ve said here.......

Posted by andrea at September 07, 2002 06:18 PM

Comments

You have inspired me to reread some of my research on doulas, so I will get back to you on that.

I don't think there are enough doulas in the USA to make an impact on the national c/s stats. However, it might be interesting to see an individual or better still collective doula's stats and compare them. I think DONA (Doulas of North America) has been collecting data for several years and so should have some info on this. The same goes for homebirth midwives while as a group in the USA they have at last count a c/s rate of between 5 and 10% (I am not sure of the actual number)because they represent maybe 1% of the birthing women's population their overall impact on National stats is small.

Despite it appearing to be a craze, many women in the USA wouldn't know what a doula was. My friends know because they know me. I would offer that having a doula at your birth is no more a craze than having a homebirth is.Unfortunate, I think.

In my limited experience as a doula (I was a doula at 10 births before I went to midwifery school) all of my clients wanted a natural birth, 8 in a hospital setting. The women planning hospital births wanted to be sure that if they had interventions they understood why. They wanted someone there who was not emotionally connected to them, who knew what their birth wishes were and could liase between them and staff, they were very disatisfied with their prenatal care especially the time available to talk with their care provider, they didn't feel listened to. Their friends and partners felt overwhelmed and all felt the need for support. One of these women was a vbac and she really wanted a vaginal birth which she achieved.

The other two women were homebirthers with a homebirth midwife. One was my personal friend from our doula training and may participation was more for me than her, however she turned out to be one of those mums who had her first baby second: she had had a 2 hour labour the first time and a 26 hour labour the second. She actually really needed me as the midwife had a couple of other ladies due too, and so was resting herself for the birth, so I was actively supporting my friend. The other was a very needy woman who the midwife felt needed extra support that again because of a very busy practice the midwife was unable to give. It worked well. Now I know that some of you will question this type of over extended midwifery care, however there is a delicate balance too in independent midwifery care between attending enough births and making a reasonable, liveable income. Another debate.

Did I make a difference at the births, I think so. One lady had a c/s (footling breech at term, cephalic presentation at last OB consult with u/s), all others were vaginal births, and to be honest all would have been vaginal without me. The only difference was that the women felt listened to. That was the difference I made. The sample is obviously too small to make any other statements.

Did I feel disappointed and burnt out, disappointed yes, not burnt out. Disappointed not with the births I attended but with the number of women who called me and when interviewed wanted a person to ensure they "got their epidural in the parking lot". I also dislike self promotion, I can talk or write my head off but the self promotion needed to make a living as a doula was overwhelming to me. I had to be honest and disclose that I was in fact an advocate of natural birth. Thus I selected the clients I worked with. There is quite considerable debate in doula circles about this attitude. I also fell in love with midwifery, so I used my experience to go to midwifery school.

I don't think there is enough money to be made as a doula that justifies the work in anyone's mind. It is most always a labor of love, with the money just covering expenses if that.

You have highlighted the inequalities in doula care: there just aren't enough for every woman who might want one, and if not funded how could all women afford one?

I will get back to you on the reasearch.
marilyn

Posted by: Marilyn Kleidon on September 9, 2002 12:18 PM

Comments

Dear Andrea,
What are you afraid of?
Why are you questioning any woman wanting to support women at birth?
Why does the system have to change from the top only - isn't flexibility one of the most important things promoted at birth classes?
Isn't our job as women midwives/doulas/educators, hard enough without a slap in the face from the very woman who promotes herself as an advocate of positive birth?
In my experience a doula has found herself in the very path of birthing women out of love and compassion. Why don't you ask women who have birthed with a doula present for their views, instead of relying on statistics and prejudice.
Beth

Posted by: Beth Newman on September 10, 2002 12:47 PM

Comments

i have a 15month old son who i birthed at home with 2 midwives & my husband in attendance. depsite social conditioning i loved my birth experience & would gladly relive it over again. i also have a background in natural therapies with which i was specialising in the childbearing year. it wasn't until i had my own birth experience that i decided to heed to the calling of midwifery. Unfortunately with Australia being the way that it is, direct-entry midwifery is currently not an option for me, & i don't have any desire to take up general nursing first. so, the next logical step in my journey to that time when i can become a midwife was to become a doula. i was already attending births in the capcity of a natural therapist but i decided that training to be a doula would give me that extra skill needed in 'mothering the mother', i already had a supreme confidence in woman's design & ability to birth naturally which i am very passionate about & take to these births wholeheartedly. becoming a doula was another tool in my belt to help these women. the midwives that i worked alongside were very positive & happy to have me there.most importantly, so were the birthing couple.
so, Andrea in your assessment on the need of doulas, is my experience wrong. with the current status of midwives in Australia, many staying safely within the hospital regime, isn't it beneficial that doulas are present, if nothing more than to ensure women that they are completely capable of giving birth naturally & therefore bringing about social reform in attitudes toward birth?

Posted by: Michelle on November 22, 2003 11:15 PM

Comments

You may find it interesting to visit the sites about poker card, casino no deposit, online casino casions, gambling cash, blackjack sites, roulette casions, gamble tip, internet casino web, slot machine odds, online casino bonus deposit, online gamble game, casino gambling strategies, casino game strategies, las vegas table, video poker casinos, roulette online card, slot rule, blackjack online deposit, blackjack betting 3d, poker 888, gambling 8888, blackjack tip, poker on net, casino casions, casino gaming, gambling no deposit. .

Posted by: blackjack on January 19, 2004 08:05 AM

Comments

You may find it interesting to check the pages in the field of phentermine effect, zyban tablet, viagra cream, propecia for woman, online pharmacy prescriptions, tramadol mens, ultram 400mg, wellbutrin resistance, paxil overnight, meridia comparing, zyrtec online, xenical cheap, vioxx 12 5mg, vaniqa dosage, retin a canada pharmacy, prozac on line, generic viagra 10 pills, celexa woman, buy phentermine addiction, xenical capsules, ambien substitute, dilenyoung about, hopforyou pills, kip980 perscription medication, mng765 what is, pol_uri facts, piter_gordon mail order, miss20092000 2 month supply, robert_zed2003 fasten, fp292003 men, diagodream supplements, jacglen2003 can i, lisa_plamer products, gill_bern review, gtrgtr45 100mg, poklop2000 men`s, nolzer12 men`s, rtopopi mail order pharmacy, oklokol for woman, racertroy2003 information on, viagra information about, phentermine alternative. .

Posted by: fp292003 on January 21, 2004 01:54 PM

Comments

I am a doula and a midwife's assistant in the United States. I agree that the midwifery model being strengthened and promoted is what will make the most positive changes in childbirth.

Something you may not have considered is that doulas advocate for normal birth - not the typical American birth. I spend hours with my doula clients prenatally educating them on birth - and on how medical management alters that normal process and can cause complications.

Doulas in the United States are sharing information that is not dispersed in the mainstream - women and families are hearing about their choices for the first time! Most of our clients only know what they have watched on television (horrid!) and what they have heard from friends and family.

I have had clients who switched care providers, changed from hospital to home birth, and who have decided with the second pregnancy to have a home birth.

So doulas are not just providing a much needed service - that of education and support - but they are also helping the midwifery movement one family at a time.

Posted by: Kellie Fuller on April 5, 2004 05:29 AM

Comments

I am a trained nures from South Africa. I did not train as a midwife but became a lawyer instead due to the poor nursing pay. I then went to live in Israel and last year became a doula. I have read your diary with interest.

Posted by: leah amdur on June 29, 2004 11:11 PM

Comments

I noticed that breathing doesnt work in the hospital in labor and that hypnobirthing is impractical as well when the mother is hooked up to the monitor. I agree with your concept of midwifery and while I have been reading all the info about doulas on the net.

Posted by: leah amdur on June 29, 2004 11:22 PM

Comments

I must say I felt the dissonance between the outlook of the medical profession and the claim of the doulas. Being a nurse and a lawyer I was amazed that the doulas were acting as midwives and attending homebirths with no legal fall out and deaths until I extended my reading. What also does not sit well with me is the fact that doulas regard those in the medical profession as incompetent and dangerous.

Posted by: leah amdur on June 29, 2004 11:24 PM

Comments

On the other hand I definately see the need for a doula to help women with their labor at home. Especially in the cases where women labor for 3 days. If a doula keeps a woman from going to hospital where in Israel they could be hooked up to a monitor and induced in the early stages of labor they are doing a good job.
Also for the English speaking mothers who come here and do not speak Hebrew it is very frightening to be in a labor ward and not speak the language.
I agree that doulas oversell themselves to their clients.
I regard myself as fortunate to have nursing training so I can advise my clients in a more professional way and also I work closely with the doctors and midwives and I rely on their expertise.

Posted by: leah amdur on June 29, 2004 11:26 PM