Monday, November 16, 2009

Healthy Birth Practices: Have Continuous Support

We've been talking about the Six Lamaze Healthy Birth Practices, why they are helpful in labor, what the research says about them, why these birth practices are often utilized less with women of size and how that affects our births.

The previous Healthy Birth Practices we discussed were:
  1. Let Labor Begin On Its Own
  2. Walk, Move Around, and Change Positions During Birth
Now, the third Healthy Birth Practice is:

3. Bring a loved one, friend, or doula for continuous support

In my opinion, although this is helpful anywhere, this may be particularly helpful to women who are birthing in the medical model at a hospital, and especially women of size birthing in the medical model at a hospital.

But frankly, it's most helpful if the labor support person is non-judgmental and knowledgeable about supporting women of size, and if the care provider is also size-friendly and birth-friendly.

Historic Birth Support

As the Lamaze care practice paper on Continuous Support During Labor notes, there is a long history of providing support for women during childbirth, but who provides it and how has changed over the years:
In times past, women learned about childbirth from their mothers and sisters. Stories and family traditions helped women to have confidence in their ability to give birth. Family members and women friends surrounded the laboring woman, offering her encouragement and support. Babies were born at home with a midwife.

Then, early in the 20th century, birth moved into the hospital. No longer could family or friends be present with a woman during labor. Nurses offered support, but they had to care for several women at the same time. Their responsibilities were divided among other patients, so the laboring woman was often left alone.

During the 1960s, Lamaze International and other childbirth organizations succeeded in changing the rules, so that fathers could be present in the labor room. Fathers give special, loving support to their partners and deserve to be there for the birth of their child. No longer did women have to labor alone.

Currently, women are rediscovering the value of having additional support during labor, especially from individuals who are experienced with and knowledgeable about birth. Women often assume that a nurse or midwife will stay with them throughout their labor. Sometimes this happens, but most often, other duties prevent care providers from being with only one person continuously.
So, bring a loved one, a friend, or a doula with you for continuous support during your labor. You will receive the emotional and physical support you need from one or more caring individuals. Before your baby’s birth, decide who will provide this support, and make a plan with them.
The important thing to note here is that women have traditionally sought out and gotten labor support for a reason, because this support often plays an important part of helping a woman through labor and having a more positive birth experience.

However, while doctors and nurses do their best to help, continuous support is often not available from medical personnel at the birth, because they are often busy dealing with other medical duties and therefore cannot give the kind of one-to-one support a mother may need.

This is why it is helpful to bring along someone else to help provide that continuous support during labor. This support can be helpful in any type of birth----from a totally natural homebirth to a highly medicalized hospital birth (and anything in between). It can be provided by a husband or partner, a friend, the woman's relatives, or a "doula."

Of course, there is no one "right" way to give birth. Different choices are right for different people. The important thing is that women have access to all choices, that they have adequate information about the pros and cons of these choices, and that when they make choices, their choices are respected.

However, labor can be stressful and emotional, and women and their friends and family are not always aware of the variety of care options available or the pros and cons of each. Therefore, it helps to have labor support personnel who are experienced with birth, knowledgeable about the variety of choices available during birth, and willing to support the mother in her birth wishes, whatever they are.

That's where a doula comes in.

What is a Doula?

A doula is a person who provides professional pregnancy and labor support. This is their career, so they tend to be more experienced, have more training, and be more educated about birth choices than a family support person might be.

The word "doula" comes from Greek and means "woman's servant." It referred to the women who traditionally provided support to mothers in labor.

The Doulas of North America organization defines a modern-day doula in the following way:
A birth doula is a person trained and experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during and just after childbirth.
Some doulas only work during labor itself, but most doulas work with women before and just after the birth as well. They give emotional support and information as needed during pregnancy, provide support and encouragement during labor, and then give early post-partum and breastfeeding support.

Some doulas (known as "postpartum doulas") specialize in helping the mother for a longer period after the birth, generally for a few weeks or months. They help with breastfeeding issues, physical recovery, household chores, assisting with older children, or doing whatever is most needed at the time. They can be particularly valuable after a difficult birth, during a surgical recovery, or when the mother has several older children and little family help.

But most doulas work during pregnancy, birth, and for a few days immediately after birth. In particular, they specialize in labor support.

It's the doula's job to know all the "tricks of the trade" to help a woman cope during labor, to have a grab bag of ideas to try if difficulties arise, to help parents examine their choices in difficult situations, and to provide emotional support for the parents however the birth proceeds.

Doulas do not make medical decisions for you and they don't intervene with the hospital staff. They are not there to tell you how to give birth or what your choices should be. It's up to you and your partner to make your own medical decisions and to advocate with staff on your own behalf.

However, doulas can help you talk through the benefits and risks of all the options when there are choices to make, and they can give you ideas about alternatives that might help. It can be incredibly valuable to have this objective "third eye" during labor.

Doulas are an important addition to overworked nurses and doctors who have a limited time with each patient. Partners, friends and relatives try to help out as best they can, but they may not have the experience or knowledge to help very well. Thus, doulas play an important role in helping "fill in the gap" in providing much-needed yet experienced labor support.

That doesn't mean that friends or relatives cannot help. Research shows that outcomes improve even when non-professional support is utilized. Sometimes just having continuous, loving support is the most important factor.

However, if you plan to use friends or family instead of a doula, it's best if they have some idea of how to support a laboring woman. Ask them to take a non hospital-based childbirth education course with you, or to read some books about supporting women in childbirth, such as The Birth Partner by Penny Simkin, or The Labor Support Handbook by Penny Simkin and Ruth Ancheta. These can help fill in some of the blanks and help them be the best possible support they can be.

But generally speaking, it is most helpful to hire someone who specializes in labor support and has a lot of experience in it.

Common Concerns Over Hiring a Doula

When discussing hiring a doula, several concerns commonly crop up. These are usually based on misconceptions about doulas and what they do.

Doulas might take away from the Dad's role

One fear that many folks have is that the doula might make the dad/partner feel superfluous or somehow make the experience less emotionally intimate between the couple.

However, in real life, many partners find that they are actually greatly relieved to have a doula. [My husband was!] It helps take the pressure off of them so they can concentrate on just being there emotionally for their partners.

Too often, partners are expected to advocate for their loved ones with very little preparation. And because they are emotionally involved with the mother, they can become overwhelmed by the strong emotions a birth can bring and forget what they do know. That's why it can be helpful to have an objective and experienced eye to remember what questions to ask, what position changes may help, what techniques can help lessen pain, and what the pros and cons of a proposed intervention might be.

Another point is that the birth can be tough on the partner as well as the mom. A doula can be much-needed support for both the mother and the partner. She can help the partner remember comfort measures that might help in labor, she can give a second set of hands to help with rubbing and holding and other physical tasks, she can stand in while the partner takes a bathroom or meal break, and she can give much-needed emotional support to both the mother and her partner.

As for interfering with emotional intimacy, a doula knows how and when to step back. She is not there to be the main support person, but rather to help the couple. She will help in whatever way they want and she adjusts her role to the needs and desires of each couple and each birth.

Thus, most couples find that a doula enhances their experience, not detracts from it.

A doula might judge me if I don't end up with a totally natural birth

Another fear of some women is that a doula might be judgmental if they decide to choose an epidural, pain meds, or other interventions like induction, breaking the waters, or a cesarean.

The truth is that there are all kinds of doulas out there. Some do tend towards pushing a natural childbirth agenda, but others know that they are there to support the mother in whatever choices she makes. Many know how to optimally support a woman with an epidural, or how to make the best of challenges like induced labor. They should know how to roll with the flow and still help you find the very best birth experience under the circumstances, without judgment.

Choosing a doula is like choosing a birth attendant---it's best to find one that aligns with your own birth desires. If you think there is a strong chance you will be wanting an epidural during your birth, then make sure you hire a doula and a birth attendant who can be supportive of that and who know tricks for supporting a woman who has an epidural. Likewise, if you know you prefer natural childbirth, hire a birth attendant and doula who are supportive of that and who won't be pushing drugs or interventions on you unnecessarily. Both kinds really do exist.

Also remember that birth sometimes carries unexpected surprises, and sometimes the person who really wanted an epidural doesn't have time to get one, or the person who really wanted a totally natural birth ends up with interventions. Having a birth attendant and doula that are flexible, non-judgmental, and who have a wide range of skills and experiences can be helpful in meeting the unexpected with grace and flexibility.

Doulas are too expensive

Another reason many parents don't hire a doula is the added expense. Doulas are not usually covered by insurance plans, and adding any extra cost during the expensive time of pregnancy and birth may not seem worth it.

However, most women who have hired doulas felt it was well worth the extra expense, and most find a way to afford a doula again in future births. Most parents find them that valuable.

Furthermore, there are many ways to be able to afford a doula, even for those who think they cannot possibly afford it.

Doulas vary greatly in cost, from very expensive to very cheap. Generally, the cost is several hundred dollars, but that may go up or down depending on how experienced your doula is, how much training she has, and the general cost of living in your community.

Shop around and see what costs tend to run in your community. Remember that doulas deserve to earn enough to help support their families, and that their time investment is usually considerable. If you figure out how much time a doula spends with you, you'll find that their flat fee often ends up being only a few dollars per hour and thus is more affordable than you might think.

If money truly is too tight to afford a doula, remember that some doulas will work on a sliding scale basis, some will barter services with you, some accept payment plans, and some doulas will work for free while they are fulfilling certification requirements (check Craigslist for ads from those who are offering free services while they train).

Many people opt out of hiring a doula because of the money, but more could probably afford it than they think. Check into all your options before you decide to opt out of a doula solely for financial reasons.

Finding a Doula

For further information about hiring a doula, contact:
  • Doulas of North America -
  • Birthworks -
  • Childbirth International -
  • The Organization of Labor Assistants for Birth Options and Resources -
There are even organizations that specialize in doulas for special needs, such as a doula for a mother whose husband has been deployed (or injured/killed) in the military, or for teen moms, etc. If you have a special situation or need, contact several doulas in your area and ask them for the names of local doulas who could offer particular support for your concern. Chances are you will be able to find someone who could meet your needs.

Click here for questions to ask when interviewing a doula. It's best to interview several doulas before you decide, and to take your time to be sure this is really the right person for you.

Not every person "needs" a doula, and many women do fine without one. If you decide to go without one, that's okay. But research shows that outcomes would probably improve overall if more women had doulas as part of their birth support team.

What Does Research on Labor Support Show?

Research shows that having a continuous labor support present at your birth lowers your risk for many interventions significantly:
Numerous research studies show important benefits to mothers and babies of continuous labor support by a loved one, friend, or doula. Labor support is a safe and effective practice with no negative side effects, yet the practice is underused (Sakala & Corry, 2008).

According to a review of studies from the Cochrane Pregnancy and Childbirth Group—a part of the highly respected, international Cochrane Collaboration that identifies best care practices based on research—continuous support for women during labor and childbirth is clearly beneficial (Hodnett et al., 2007). Study findings indicate that, compared to women who do not receive continuous labor support, women who receive continuous, one-to-one support are less likely to:
  • have cesarean surgery;
  • give birth with vacuum extraction or forceps;
  • have regional analgesia (e.g., an epidural);
  • have the need for any analgesia (pain medication); and
  • report dissatisfaction with or negative feelings about their childbirth experience (Hodnett et al., 2007).
There are good, clearly proven benefits to having a continuous support at your birth. Therefore, it is to your advantage to strongly consider a doula or other support person.

Women of Size May Benefit from Knowledgeable Doula Support Even More

Because women of size tend to be subjected to more labor interventions and restrictions and have higher cesarean rates than women of average size, professional labor support is probably even more important for women of size.....yet some women of size may be hesitant about hiring a doula because they fear judgment about their size and needs.

Many women of size know all too well that society views their bodies with disgust and judgment, and makes many assumptions about how they "must" be eating or behaving simply because they are fat. Certainly this is often true in the medical community, but sadly, this is often also true even in the "alternative" birth community.

Women of size may fear that a doula will judge their bodies harshly, or they may feel embarrassed or hesitant about exposing their curves, sags, and bags to even more people. Or they may want to avoid yet another person who will assume that they have "bad" nutrition and exercise habits that "need" fixing. Or if they do have food issues, they may be embarrassed to discuss these and face the kind of moralistic judgments that often come from folks who do not have these struggles. Fear of judgment is one of the main reasons women of size don't take advantage of doulas more often.

Furthermore, knowledgeable support for the special needs of women of size is often lacking among doulas and labor/delivery nurses. They may not know how to physically support larger women during labor, they may not realize the tremendous importance of a correctly-sized blood pressure cuff, they may be hesitant to support women of size in laboring in water, they may not question some hospitals' protocol for encouraging internal fetal monitoring and early epidural for "morbidly obese" women, and they may not really believe that fat women are capable of birthing normally.

This may lead many fat women to choose to only have loved ones with them for support during labor. But although friends and loved ones can provide good support during labor too, they may have their own secret fears, concerns, or judgments about pregnant women of size.

Too often, doctors capitalize on these fears by convincing partners and family members that the mother "needs" a cesarean or induction for reasons that are not supported by research, like macrosomia (suspected big baby). Unless the friend or loved one is really savvy about birth issues, it's all too easy for them to become another voice in the chorus telling fat women to just take the cesarean and move on.

Women of size need to know that there are doulas out there who won't be judgmental about their body, who won't assume that they have terrible habits simply because they are big, who won't try to "fix" them or sniff in disdain if they end up having a cesarean or less-than-perfectly-natural birth.

There are doulas who don't buy into the medical model consensus that obesity "necessitates" a high-tech approach to birth, and who understand that fat women can give birth vaginally too, if given a real chance. And there are doulas who can and will support fat women lovingly, however their births proceed.

It can be very helpful for women of size to find such doulas and utilize them in their labors---especially in a hospital setting where an extremely interventive approach to birth for "obese" women is very common.

However, doulas are not miracle workers. They can't override choices made by birth attendants. If you hire a high-intervention provider and he/she decides to induce by 39 weeks because "we don't want the baby to get too big," there are only limited things a doula can do to mitigate the increased risk for cesarean that such a choice brings.

Therefore, while a doula can be very helpful, it's best to find both a birth attendant and a doula who are both size-friendly, and whose birth philosophy and approach align with yours.


Continuous labor support during labor and birth can lower the risk for cesareans or other operative birth (forceps or vacuum extraction), it can lessen the need for pain medications and epidurals, and mothers who have continuous labor support report less dissatisfaction with their birth experiences.

Continuous labor support can come from friends, partners, family, or professional labor support personnel (doulas). Professional doulas are probably the most ideal choice because of their wide experience and knowledge base, but research shows that even non-professional continuous support improves outcomes.

However, if you choose to use non-professional support, be sure that person is well-versed in labor support techniques and understands the pros and cons of various birth choices. A childbirth class and a book on labor support can be very helpful in preparing them to be on your labor support team.

If you do choose to hire a doula, it's important to shop around for a truly size-friendly doula....but the good news is that there ARE size-friendly doulas out there and that they may be particularly helpful in lowering the risk of unnecessary interventions in women of size, particularly those birthing in the medical model at a hospital.

However, it's the combination of a truly size-friendly, birth-friendly doula and birth attendant that is most optimal.


Karen H said...

As an obese women of 200 pounds or so, I enjoyed two natural births with the help of an experienced doula. She attended both & was of great assistance during the triple-peak contractions with #1 son. With #2, she was instrumental in moving me around, keeping my labor productive, helping me in and out of the tiny shower in the labor room. I had a birth plan, and both the OBs had worked with the doula before & supported natural births. I did not feel my size was ever an issue, perhaps since I was at risk as an older mother with infertility issues and that overshadowed my weight. As you mentioned, my husband was relieved that she was there, too. I would urge any woman to consider hiring a doula!

Robin Elise Weiss said...

I have to say that we often have more than one doula at our births. It was very important to have help throughout my typically long labors. My husband wouldn't even think of having a baby without a doula. Very through article about doulas! Thanks!