Doulas - Who Are They and How Might They Affect Obstetrical Anesthesia Practices?
By
William Camann, M.D.

Childbirth. It is one of the most important events in the life of a family and an experience that most women will remember and, hopefully, treasure for the rest of their lives. A pleasant birth experience can facilitate the creation of a strong bond between parents and infants. These powerful emotional ties should have lasting positive effects on individual families and society as a whole. For centuries, the concept of emotional support for women, by women, during labor has been accepted practice. It is only in recent decades that fathers have taken an active role in the birth process; women have traditionally given birth in the presence of other women. Artistic and literary descriptions of birth from ancient and primitive cultures usually depict other women acting in support of the parturient. The modern doula is a manifestation of this support person.

What is a doula? A doula is a woman experienced and professionally trained in labor support. Doulas are usually of lay background, but often have worked as labor nurses, as childbirth educators or in other obstetric areas. They provide the parturient with praise, reassurance, comfort measures and companionship. The word "doula" is derived from the Greek for woman servant. Doulas are to be distinguished from labor nurses in that they perform no clinical tasks nor do they assist with traditional nursing functions. Doulas are also to be distinguished from midwives or obstetricians, as they perform no medical tasks nor do they assist in the actual physical act of the birth.

The role of the doula is to provide emotional support, companionship, physical comfort measures and encouragement during labor and delivery. She also supports and guides simultaneously; midwives and obstetricians are generally not in constant attendance with the laboring woman, and even the women's partner despite love, devotion, childbirth education classes and best intentions may be of only limited (but certainly not unimportant) help during the actual labor. In fact, one recent randomized trial of hospital-based doulas found that over half the women rated the doula as more useful than their husband during labor.1

Doulas are readily available and becoming more popular. The Doulas of North America Web site www.dona.org provides much information, including links to hundreds of doula agencies and individual doulas in most locales around the country. Some hospitals provide access to doula care, although most are arranged by private contract. Fees are variable, often negotiable and range from nominal to up to $1,500 per labor (the latter being largely in affluent metropolitan areas).

In what manner will obstetric anesthesiologists interact with doulas? Frequently, the interaction will be minimal or nonexistent, as many doulas are strongly committed to nonpharmacologic methods of pain control, and many patients who seek doula support are equally committed to attempting a medication-free labor. Nonetheless, an increasing recognition of the importance of emotional support during labor, combined with the ever-increasing popularity (and safety) of modern regional analgesic techniques for labor, has resulted in some women requesting doula support even with the intention of receiving regional analgesia in labor.

While some doulas will limit their client base to those women who only desire to labor without medications, it is not the role of the doula to make this decision for the woman. Excerpts from the Doulas of North America Code of Ethics and Standards of Practice include: Doulas do not offer second opinions or give medical advice. Doulas do not make decisions for their clients; they do not project their own values and goals onto the laboring woman. The doula's goal is to help the woman have a safe and satisfying childbirth as the woman defines it [author's emphasis]. Many women choose or need pharmacological pain relief. It is not the role of the doula to discourage the mother from her choices. The comfort and reassurance offered by the doula are beneficial regardless of the use of pain medication.2

Some obstetric anesthesiologists are of the belief that doulas will exert undue pressure on women to avoid epidural analgesia. There is reason to believe this to be true. The DONA Web site reports that meta-analyses of randomized controlled trials find that doula use is associated with fewer requests for epidural analgesia. 3 However, some individual studies have not found this to be true. One recent randomized study claimed that doula use was associate with less overall requests for epidurals, yet closer examination of the data reveals that this finding was barely statistically significant.1 Furthermore, it was only true in two of the three hospitals where the study was conducted, the third site having actually more requests for epidurals in the patients with doulas. Nonetheless, other studies do support less frequent requests for epidurals in women with doula support and also less need for operative delivery and oxytocin use. 4

Are doulas necessary if a patient receives an epidural? Relief of pain does not obviate all emotional distress and anxiety during labor. Concerns about welfare of the neonate, length of labor, fear of the return of pain, fear and anticipation of the approaching second stage of labor, fear of alterations in body image and loss of dignity during childbirth, among many others, are all valid sources of anxiety even in the presence of a well-functioning epidural analgesic. Support and reassurance, as professionally provided by a doula, can be invaluable to some women in these circumstances.5

There will be instances where a woman and doula, both staunchly committed by prior agreement to achieve natural childbirth, will find that epidural analgesia or operative delivery is requested or suggested owing to a variety of unpredictable circumstances during labor. Disappointment may prevail, as both mother and doula may sense a feeling of failure in their respective roles. It is here, in my opinion, that the mature doula can have a great impact. Reassurance that not all labors unfold as planned, that mother and baby are safe and reminders of the good intentions of relevant medical care providers is paramount at these times. Anything less would be a disservice to the parturient.

It is for precisely these circumstances that, in my opinion, all doulas should have experience with regional analgesia as part of their certification process. Even the most ardent proponent of natural childbirth will be a better doula to all her patients, both with and without epidurals, if reasonable exposure to and knowledge of modern-day obstetric anesthesia techniques is obtained. Exposure to new and innovative techniques of regional anesthesia, such as combined spinal-epidural analgesia, patient-controlled epidural analgesia, walking epidurals and ultra-low-dose epidural infusions, should be an absolute minimum. Most importantly, doulas must recognize which patients may, for medical or anatomical (e.g., airway) reasons, present anesthesiologists with particular challenges in the event of general anesthesia. In such patients, the relative risks and benefits of having versus not having an epidural need to be considered carefully and discussed with the patient and the primary obstetric care provider.

This dialogue must be a two-way street. Just as doulas must acknowledge that not all obstetric anesthesiologists are the enemy,www.dona.org/positionpapers.html" so must obstetric anesthesiologists acknowledge that not all doulas are created simply to talk their patients out of receiving epidural analgesia. We must be aware of and acknowledge the tremendous life-event that childbirth is and should be. We must be aware of the centuries-old tradition and importance of emotional support in labor. Relief of pain and emotional support and reassurance are both important contributors to a positive birth experience. Not every woman in labor wants or needs a doula, but neither does every woman want or need a regional analgesic. Nonetheless, we, and all our doula colleagues, must agree that doula support and regional analgesia in labor are entirely compatible and complementary adjuncts to a safe and satisfying birth.

The author would like to thank Penny Simkin, one of the founders of DONA, and Debra Brewster, a past president of DONA, for valuable assistance with the preparation of this article.

References:

1. Gordon NP, Walton D, McAdam E, et al. Effects of providing hospital-based doulas in health maintenance organization hospitals. Obstet Gynecol. 1999; 93:422-426.
2. Doulas of North America Web site. Available at . Accessed September 22, 1999.
3. Hodnett ED. Caregiver Support for Women During Childbirth. Oxford, England: Conchrane Library; May 17, 1999.
4. Zhang J, Bernasko JW, Leybovich E, et al. Continuous labor support from labor attendants for primiparous women: A meta-analysis. Obstet Gynecol. 1996; 88:739-744.
5. Simkin P. The doula and the epidural. Childbirth Instructor Magazine. 1996; 6:34-35.