A Doula Makes the Difference!
Issue 87, March/April 1998
Karen Nugent

We couldn't have done it without our doula!

Despite difficulties encountered during an arduous 96-hour labor, my husband Paul and I cherish the birth day of our first child.

We were fortunate to have a doula who provided continuous emotional and physical support, and worked as our advocate to complement the midwife's medical expertise. This personalized labor assistance enabled us to achieve our childbirth goals, which included birth without medication or other unnecessary medical intervention. We couldn't have labored alone as successfully.

The doula made the difference.

Doula is a greek word meaning "woman helping woman." Dana Raphael first coined the term in her book The Tender Gift, which underscores the fact that women need women to assist in childbirth and to provide continued emotional support and guidance throughout the joyous and turbulent postpartum time. A doula, by definition, is present to serve. She helps a woman integrate the day she will never forget.

"Labor support is Centuries old, but its advantages have now been validated in six controlled studies, and its positive benefits should not be overlooked," says neonatologist Marshall H. Klaus, MD, adjunct professor of pediatrics at the University of California and director of academic affairs at Children's Hospital in Oakland.

According to research conducted by Klaus and his partner, John H. Kennell, MD, professor of pediatrics at Case Western Reserve University School of Medicine, the presence of a doula during the laboring process reduces the need for a cesarean by 50 percent, length of labor by 25 percent, use of oxytocin by 40 percent, use of pain medication by 30 percent, the need for forceps by 40 percent, and requests for epidurals by 60 percent. Comparable research studies on the effect of doula support have been analyzed by precise statistical methods and published in the Journal of the American Medical Association and the New England Journal of Medicine.

Along with the psychological and physical benefits of labor support, there are significant financial advantages. Klaus and Kennell report that births assisted by doulas could mean a $3,500 savings for individual families, and therefore reflect a $2 billion annual reduction in national medical care costs associated with labor and delivery. And no one can put a price on a woman's birth memories.

In recounting the success of our doula-assisted birth with family and friends, we discovered that few people truly understand the affirming advantages associated with a doula's services. Many wonder how a doula enhances the laboring woman's process when she already has a partner present who has attended childbirth education classes and a midwife or doctor attending the birth. Some fear that the doula will interfere with the couple's intimate experience or conflict with medical assistance.

However, more frequently than not, adequate emotional nurturing for the laboring woman is not routinely provided by mainstream medical caregivers. Doctors have separate concerns requiring medical expertise that take precedence over providing constant emotional support. As a result, women are too often encouraged to accept induction of labor, epidural pain relief, episiotomy, or other unnecessary medical intervention "to speed labor along," rather than offered encouragement to value their own inherent process and power to give birth naturally.

We located our doula, Lori, through a birthing center. I was aware of Doulas of North America and found out that she is a member, so I telephoned her to see if we were "a match" before Paul and I met with her in person. From our first conversation, I knew that she would be the one to help us through our big event. She provided us with specific information regarding her services, along with a portfolio containing a job description and a contract outlining our agreement for services and fees. The contract included unlimited prenatal consultations, early labor and delivery support, transportation to the birth site, continuous care until two hours postbirth, lactation assistance, and postpartum care. The orientation packet also contained information on nonmedical support techniques for labor and birth, inducing exercise, acupressure, massage, aromatherapy, herbal therapy, color therapy, and use of a birthing ball--a large gymnastic ball for sitting or rocking. This was my favorite birthing tool, as it helped immensely with the incredible back labor I endured.

A three-hour consultation with Lori and her partner followed this first meeting. We discussed my needs for labor support and began to formulate a birth plan that, when complete, would be duplicated and distributed to any medical personnel we would potentially come in contact with at the birth. Having this plan in hand would enable us to focus on the birth, rather than having to be concerned about conveying our wishes to people we hadn't met. This became one of our most beneficial exercises, especially when we unexpectedly found ourselves in the hospital on the night before the birth.

The series of events that preceded our overnight stay in the hospital unfolded like this: Paul had tirelessly comforted and coached me through contractions for two days and two nights before we decided we needed to utilize Lori's fresh perspective and much-needed energy. She arrived on the morning of the third day, fixed Paul something to eat, and sent him to bed. Lori labored with me all morning. She brewed fragrant herbal tea and read poetry to me while I enjoyed some relief in a warm bath encircled in candlelight. She massaged me with lavender and patchouli oil, and reminded me to drink lots of juice and use the bathroom frequently to keep labor steady and efficient. We listened to music, rocked on the birthing ball, and mirrored yoga poses, as squirrels raced across the rooftop.

By early afternoon, contractions were difficult to manage. Paul packed the car, and we called the midwife. She wanted us to come in to the birth center. Once there, after a 45-minute drive with intense contractions coming every five minutes, the midwife examined me and found that I was 90 percent effaced, but my cervix was not dilated. Paul and I were discouraged and exhausted. Lori offered words of encouragement and praise for our hard work and commitment to the task at hand.

Knowing that we strongly desired an unmedicated, natural birth, the midwife recommended that I go to the hospital for a sedative to help me sleep. She felt that with rest I would more likely be able to manage the more painful phase of active labor yet to come. So, after careful consideration, we went to the hospital. Lori stayed with us all night. I woke up at 4:00 a.m. with bloody show. A full moon was out to greet us in the black morning sky. I knew that this would be the day.

The change of scenery from home to hospital had lessened the intensity of contractions; however, they were still rolling over me every five to seven minutes. Newly motivated after seeing the bloody show, yet feeling like settling in to nest, I began to move into that hazy world characterized by trance-like concentration required to sustain the business of birth--a place where sea meets sand and tide pools swirl when stirred like drops of white paint in a gallon of blue. Paul and I were both in a daze. We heard Lori remind us that we wanted to have our baby at the birth center. Paul got the nurse and, after I had been hooked up to the fetal monitor for two hours--"hospital procedure"--we were finally out of there by 6:00 a.m. and on our way to the IHOP for breakfast.

While Lori and Paul finished breakfast, I walked around the restaurant chewing on a piece of English muffin and having contractions. Pancake syrup bottles became focal points, as the toothless waitress gave me advice and worried over the . poached egg I had just eaten. Outside, the dawning of the full moon cued us to move on.

After checking in at the birthing center to find that I was only 3 centimeters dilated, we decided to go to a nearby bed and breakfast to continue with our labor management techniques before returning to the birth center for the final push. The periodic changes in location seemed to help us feel like we were moving forward in what would have otherwise seemed like an endless, frustrating ordeal. Paul called friends and family, while Lori and I focused on tidal waves of contractions. She encouraged me to trust my own instinctive process and empowered me with a sense of inter-connectedness to all women who had given birth before me. We slowly swayed back and forth together, listening to the comforting rhythm of Enya's Watermark.

At long last, we made the final trip to the birth center. Paul and Lori worked together to keep me comfortable. Paul's presence gave me a grounded feeling of safety, and Lori was the only one who could effectively relieve my three hours of excruciating back labor, by using acupressure techniques. We were fortunate to have our favorite two midwives on call that day, making the experience extra special.

When the urge to push overcame me, I sank into the arms of one of the midwives. Lori whispered words of praise. Paul embraced me with his smile, as he watched the miracle of Kevin Paul's birth. At 4:55 p.m., Paul lovingly placed our son in my arms, as Lori quietly observed our joyous family union. We couldn't have done it without her!

At our postpartum closure meeting, Lori presented us with "The Birth Story," a written narrative of our experience from her point of view. It was beautifully written, straight from the heart. She visits us periodically to see how we are coming along as a family. On Mother's Day, she telephoned to wish me a happy day and to remind me of my great accomplishment. I feel the sense of pride and identity that Livingston describes, and I now clearly understand why Dana Raphael entitled her book about the positive impact of women helping women give birth The Tender Gift. Today, DONA carries on this tradition, helping women and families across North America.

THE ROLE OF THE DOULA
Doulas of North America (DONA) is an international organization of doulas cofounded in 1992 by childbirth educators Penny Simkin, PT; Annie Kennedy; Klaus and his wife Phyllis H. Klaus, MEd, CSW; and Kennell. According to the standards of practice outlined by DONA, the doula "advocates for the client's wishes as expressed in her birth plan, in prenatal conversations, and intrapartum discussion. She helps the mother incorporate changes in plans if and when the need arises, and enhances communication between client and caregiver." Likewise, the doula provides solace and support to the woman's partner. Conversely, the doula does not perform clinical or medical tasks such as taking blood pressure, temperature, checking fetal heart tone, doing vaginal examinations, or postpartum clinical care. Rather, she is present to offer comfort and provide gentle reminders, in keeping with the predesignated birth plan.

"A doula gives straight from her heart to help another woman discover what birth and life are really all about," says Connie Livingston, RN, DONA director of publications, and ASPOI/Lamaze educator. Doulas help women achieve "birth the way it was supposed to be," adds Livingston. "They bring a calming feeling, in such a hurried society, to the deep and spiritual experience of birth and, as a result, enable women to look back on the day they give birth with a sense of pride and identity."

DONA'S primary goal is to increase the availability of trained doulas in North America, through an international certification process. Their communications network connects certified doulas with pregnant women interested in their services.

"DONA helps women join together to network with and support each other, in order to facilitate better and more economical health care for women," says Jennifer Nunn, DONA membership chairperson.

Membership is the first step toward DONA certification. Members subsequently receive a subscription to International Doula, the organization's quarterly newsletter; discounts on DONA-Sponsored conferences, workshops, and training; and an information packet outlining certification requirements. Currently, DONA has 2,150 members and 425 certified doulas.

DONA-certified doulas are trained in the emotional and psychological processes of labor and birth; the anatomy and physiology of reproduction, labor, and delivery; comfort measures and nonpharmocologic pain relief techniques; appropriate topics for prenatal and postpartum discussion with clients; ethics and standards of practice for the doula; communication skills; and values clarification.

Certification requirements also include submitting recommendation letters, after providing continuous labor support, from three clients and either three nurses and two doctors or three midwives. Aspiring doulas must also maintain records from attending births, summarize selections from an extensive list of required reading, write a paper on the value and purpose of labor and support, and complete one of the following trainings: childbirth education; midwifery; or nurse's training with work experience in labor and delivery.

On request, DONA will provide an updated listing of members and certified doulas. The local chapter of the International Childbirth Education Association (ICEA) may also know of practicing doulas in specific areas. Call 612-854-8660 for the current schedule of the ICEA Doula Certification Program.

August 20 to 23, 1998, DONA will host its fourth annual international conference in Clearwater Beach, Florida, for all who support women and families in the childbearing years. Nunn is coordinating the event and expects a distinguished panel of speakers, including Penny Simkin, PT, and Marshall H. Klaus, MD.

For additional information on DONA, contact them at 206-324-5440, http://www.DONA.com, or AskDONA@aol.com.

Karen Nugent is an adjunct instructor in the Humanities and Social Sciences Division at Central Florida Community College in Ocala, Florida, where she lives with her husband, Paul, and their son, Kevin (2).