The Role of the Birth Doula - Realities and Misconceptions

I regularly get asked what a doula does and people sometimes mistake me for a midwife.  I have covered the difference in other posts, but basically a midwife is a medical professional who is trained to deliver babies.  As a doula, I work alongside your doctor and nurses to provide emotional support and offer suggestions for comfort measures such as: positions, massage and pressure techniques.

In my last post, I reviewed the book Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience.  The authors of this book are big fans of the doula and there is an entire chapter devoted to how a doula helps.  Because they are such promoters, I am wary of being critical of the contents of this chapters, but I felt like some of their explanations could be clarified.

DOULA vs. CHILDBIRTH EDUCATOR
First, I just wanted to clarify that a doula and a childbirth educator are different things.  Some doulas are trained as childbirth educators, but not all.  Many childbirth educators will teach classes, but will not attend the birth of your baby.  In the book, the distinction is not made clearly.  I am trained as a doula, not as a childbirth educator.  As a doula, I do offer information and resources about birth and I certainly will recommend books and dvds to clients, but I don't offer in depth classes.  There are options in our area for Lamaze and Hypnobirthing classes and I will connect clients to these (and might even attend the classes with them).

I hope to become a childbirth educator for Birthing from Within in the next three years and I am taking the first training in June 2011.  This will enable me to help couples better prepare for their birth and eventually offer classes that compliment my birth doula services.

DOULA TRAINING
In Your Best Birth, Ricki Lake and Abby Epstein say that doulas start by doing a course and then apprentice (attend births) with more experienced doulas before becoming certified.  Maybe this is the case for some doulas in some communities, but in my community the hospital only allows two support people, so it is difficult for more than one doula to attend a birth.  Also, there are very few experienced doulas here who are able to act as mentors.  I think an apprenticeship for new doulas is an ideal scenario, but do not be surprised if your doula has not had the opportunity to work with a more experienced doula.  I am trained through DONA International. For more information about their certification process click here.

DOULAS and DECISION MAKING
Lake and Epstein understand what doulas do, but they don't always explain it well.  The statement: "Doulas can help you make the decisions you're faced with during childbirth" is a good example.  I help couples prepare before the birth and provide them with information that they are interested in, so they can make decisions during labour.  One of the tools I use to do this is the B.R.A.I.N. acronym.  Couples can ask these questions of medical professionals about suggested interventions:

Benefits - what are the benefits of this?
Risks - what are the risks to mother and baby?
Alternatives - is there anything else we could do instead?
Instincts - what do the parents' instincts tell them?
Nothing - what happens if we do nothing?

This allows couples to ask questions and the medical staff to respond directly to them.  As a doula, it is important for me to maintain a good relationship with the caregivers and not be viewed as confrontational.  Also, as I mentioned in my last post, it is important that parents educate themselves and learn to advocate for themselves.

DOULAS HELPING your SUPPORT PEOPLE
This is an area that was covered well in the book.  You are the star of your birth and everyone else is the supporting cast.  As a doula, I want to help the pregnant woman feel confident and powerful and to help her partner (or other support person) do the best job they can to help her.  Often, the most important thing a doula can do for couples is to reassure them they are doing well and that this is what labour looks like. Most people have not seen anyone in labour (TV doesn't count), and don't know what to expect.  If they are fearful or in a really medicalized environment, anything that happens can be seen as potentially dangerous.  Labour is very intense and sometimes the role of the doula is to remind the support people (and the mother) that birth is not an illness and what is happening is normal.

I hope this post helped clarify some of the more complex questions of what a birth doula can help you with.  Please feel free to contact me for more information or an initial interview.

Your Best Birth

I have recently finished the book Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience by Ricki Lake and Abby Epstein, who made the filmThe Business of Being Born, which is a documentary about birth in America.  I watched the film more than two years ago when I was pregnant and I really enjoyed it.

Overall, I enjoyed the book too, although it was not as clear and well written as some other books that provide an overview of birth options, such as Ina May's Guide to Childbirth.


TAKING BACK THE BIRTH EXPERIENCE
"This book will serve as a reminder that giving birth is something that women instinctually know how to do, and that you can tap into your own innate sense of power to take back the birth experience."

This idea of taking back the birth experience is central to this book and central to what I try to do as a doula.  Instead of being passive consumers, pregnant women and couples are actively preparing for birth, researching options, educating themselves about childbirth and preparing emotionally as well as physically for the experience of giving birth. A doula can help you with this, but ultimately the responsibility for preparing is that of the pregnant woman.

FEAR AND STRESS DURING LABOUR
In Your Best Birth they talk about the role the fear plays in undermining labour.  Mammals will stop labouring if they feel threatened and this is also true of humans.  In a hospital setting, with bright lights, medical procedures and interruptions, some women will find their labour slowing down or even stopping completely.  They experience a spike in catocholamines (such as adrenaline and cortisol) and this inhibits their ability to produce their own oxytocin (which creates strong contractions).  So artificial oxytocin (pitocin) can be used, which results in extremely intense, sometimes painful contractions that can cause fetal distress.

Another way that fear can affect labour is if there are unresolved issues or concerns the mother feels going into the labour.  Some questions they suggest asking include:

• What was your initial response when you realized you were pregnant?  Have their been any changes in your attitude or feeling since then?
• How has this pregnancy affected your relationship with your partner and other family members?
• If you have given birth previously, what was it like for you? Is there anything you would change if you could? Is there anything you do similarly the next time you give birth?
• How do you envision the birth of this baby? What is important to you? Who will be present at the birth?

While this book does a good job of addressing potential fears that could affect labour, I think they could be more careful with the writing as sometimes their comments could increase potential fears.  For example they mention choosing between an episiotomy and a tear, without talking about ways to avoid tearing for another 100 pages.

CHOOSING YOUR 'TEAM'
Lake and Epstein comment that women are people pleasers by nature, and this sometimes means that we will worry about how everyone else feels before meeting our own needs.  In birth, we must put ourselves first in order to make sure the birth is what we want.

This is key when choosing our support people.  The authors suggest having people at the birth who you trust completely, who approve of your birth plan and who you won't be self-conscious being naked around.

At the Lethbridge Hospital, woman are usually allowed only two support people, including their partner/husband.  What that means is that pregnant women need to choose between having their mother or a doula.  This can be a difficult choice, as a doula has all kinds of tools that a family member might not have.  Then again, a mother might know her daughter really well, or maybe her sister had a great birth and could be extremely helpful.  I think this something where a pregnant women should trust her instincts.  As long as the person they choose will be able to really support them, that is what matters the most.

What about partners or husbands who are afraid for their spouse or not supportive of her choices?  It is so important that the role of researching and preparing for the birth is a joint role.  Also, a doula can really help the father, both in preparation and during the birth experience.  As a doula, I hope the partner will be the primary support person, with me providing suggestions, reassurance and comfort techniques that he can use.

Your Best Birth cautions that we have realistic expectations of our support people (whether a partner, family member or doula). Although we can expect them to share our preferences with health professionals during labour, we can't expect them to argue against necessary medical procedures or body block the anesthesiologist.  I am preparing another post to further address the role of the doula as it laid out in this book.

LOCATION OPTIONS
This book is a strongly slanted towards natural birth and especially home birth with a midwife.  It can be frustrating to Lethbridge mothers, as this is not currently an option in our community.  The are no licensed midwives based here and the midwives working in Calgary have waiting lists for Calgary clients and are not usually willing to take clients from Lethbridge.  Hopefully that will change in the near future.

The most important thing to remember is preparation.  Knowing what you want your birth to be like and having a team (possibly including your partner, family members and/or doula) who are on the same page with you.  It can be important to have a doctor that you trust, but it is also important to remember that your doctor will likely be present only at the very end of your birth and many doctors (both family doctors and obstetricians) take turns being on-call, so your own doctor might not be at your birth.  You need to ask your doctor about this, if it is important to you.

From the last paragraph of Your Best Birth:
"...when women feel safe and empowered around their own births, they are able to bond with their babies and enter motherhood from a place of strength and security.  We have a long way to go toward making this a reality for every expectant mother, but through sharing information that will support woman through this journey, we are moving closer.  Our babies will thank us."




Overall, an inspiring book and well worth the read.  I also recommend the film, especially for couples to watch together.