Is a doula a need or a want?

is a doula a need or a wantAs a doula I’ve been contemplating this question for awhile, attempting to evaluate whether I’m presenting my services appropriately. Ever since hearing Suze Orman declare that a doula is a need and not a want, I’ve tended to side with her argument.

But lately I’ve been thinking more pragmatically about the topic and have realized that of course women do not need a doula. (If they did, there wouldn’t be such a thing as an unassisted childbirth.)

To be able to quantify the value of a doula, first we have to get back to the basics of women’s empowerment: women are strong and capable of giving birth and caring for their babies. Regardless of the perceived value of a doula, the woman chooses whether to hire one or not, so by definition, a doula is not a need. Whether a mother is completely alone when she gives birth or has a room full of attendants doesn’t change the ultimate outcome. (At least I’ve never heard of a case of a baby staying inside the womb forever!)

Just like with all choices, when choosing her birth team she weighs the benefits, risks and alternatives. Although women should feel entirely free to choose their birth attendants, due to insurance and other influential factors, that is not always the case, but that is a different topic.

For some, the team of birth attendants is going to include a doula – a trained, experienced professional who “helps to inform, increases awareness, and mentors the mother and family during, before and after her baby is born.” (DTI)

For those who may believe a doula is the expendable member of the team, let’s just revisit what each person does when the birthing room is full. (By the way, the room is never full until the one giving birth has all the people with her whom she wants to invite in.)

The mother: In this case it’s worth pointing out the obvious: there can’t be a birth without a mother. In a climate where the major event seems to be focusing on machines and charts and rules and regulations, we shouldn’t forget that the mother doesn’t lose the right to bodily autonomy during her pregnancy.

The primary birth partner: In most cases the birth wouldn’t be happening without the presence of the mother’s partner. In an ideal birth, the partner gets to relax a little, enjoy his/her child’s birth, and spend energy focused on just doing what he/she does every day: loving the mother. Note: The birth partner should also have an opportunity to remain involved in any decisions made in the birth room and to participate in any comfort measures being provided to the mother. Doulas often help partners feel more confident in their participation.

The obstetrician: If an OB attends your birth, you may see this person only briefly during the labor. He/she may pop in to assess progress soon after your arrival at the hospital, perhaps another time depending on how long you’re there, but likely won’t return until a problem or perceived problem arises, or until the mother is completely dilated and has begun the pushing process assisted by the labor & delivery nurse (especially if the mother is medicated and not using mother-directed pushing). Monitoring of the fetal heart rate is done remotely and the majority of the charting is done by the nurses on staff. Communication between the staff and the on-call OB occurs outside of the birthing room for the most part.

The midwife (in hospital): If a certified nurse midwife attends your birth, you can expect to see her more often than you would an obstetrician. She will remain with you for as long as she is able during your labor. If it’s quiet on the floor, she may stay with you for the majority of your labor. When the pushing process begins, she will be there to provide encouragement.

The midwife (out of hospital): If you choose a homebirth, you can expect to stay in close contact with your midwife throughout the labor process. In general, she arrives at your home during your active labor phase and remains with you for several hours after your baby is born, providing all healthy newborn assessments after the birth. She may or may not have a midwife’s assistant with her to help her with clinical tasks such as listening to the baby’s heartbeat and maintaining a birth record.

It’s also worth noting that the best prenatal care practices (in my opinion) are the ones in which the midwives provide the majority of the care and there are 1 or 2 obstetricians available for collaboration if anything outside of the ordinary comes up during the pregnancy or birth. (Perinatologists provide care for the highest risk categories of pregnant patients but may also assist in the care of low-risk women in certain cases. OBs provide care for both high- and low-risk women. Midwives focus on low-risk pregnancy and birth but are trained to know when collaboration or a referral/transfer is necessary.)

The labor & delivery nurse: As a staff member of the hospital, L&D nurses have a number of tasks they must complete as a part of their job description: completing the admissions process for each patient, adjusting heartrate and contraction monitors and charting results, communicating with the attending physician or midwife, helping moms to and from the restroom, keeping linens fresh and clean, assisting mothers who’ve had an epidural with position changes in the bed, and hopefully completing all of this with a friendly and encouraging attitude. Nurses have a difficult job, but many love what they do and it’s important to try and forge a good relationship with your nurse. Nursing shifts generally run from 7AM to 7PM, so depending on what time you arrived at the hospital, the nurse who’s there when you arrive may not be the one who’s there when your baby is born.

The baby care nurse: A different nurse arrives shortly before delivery and performs initial newborn assessments after baby is born and provides the first bath/weighing and measuring and in some cases, may assist with breastfeeding.

The doula: So with all of these people, it’s easy to see how the doula can get lost in the shuffle. Why on earth would another person be necessary? The women who hire a doula have the benefit of having a trusted person by their side continuously (her shift doesn’t end at 7 PM), who is knowledgeable and calm about the birthing process, who can interpret any hospital-based lingo, who can help forge a team atmosphere between all the key players, who can provide comfort measures, who is a second set of eyes and a calm, respectful and honest voice in the room, and whose clients request medication less frequently and give birth via Cesarean less often. (“Subgroup analyses suggested that continuous support was most effective when provided by a woman who was neither part of the hospital staff nor the woman’s social network.”)

The lactation consultant: All lactation consultants are not created equal. Because this is postpartum topic, I’m going to address it separately. Stay tuned.

Anyone else who the mother desires to have with her and who she has determined will be supportive during her birthing process: mothers, sisters, friends, children, a photographer, even male family members other than the partner – if it’s someone the mother wants in the room, it is her call. There are always jobs to do in support of a birthing mother. (See “forge a team atmosphere between all the key players” above.) By the way, if a hospital has rules about how many people can be in the labor room at one time, it is the labor & delivery nurse’s job to enforce that rule. Most hospitals are willing to make an exception, so it will just depend on how many people make the mother comfortable (or uncomfortable), and she can always change her mind at any time. If she wants her other children involved, it is wise to have an adult caregiver other than the primary partner/parent who is assigned to the sibling.

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