Safe and Healthy Childbirth - Why Every Woman Deserves a Doula

written in collaboration with Dr. Antoinette Falco, ND, Doula
 

Childbirth is one of the most transformative processes a woman can experience. While the intensity of childbirth is a constant through the ages, expectations and environments have evolved. Today, in Western culture, a woman’s first encounter with birth is usually that of her own first baby. In contrast, throughout prior recorded history, it was commonplace for women to have gained experience with birth through attending births of relatives or neighbours, prior to the births of their own children. In this article, we explore what it means to women to have continuous support of a nonmedical professional, such as a doula or professional birth partner, in addition to their medical support team at their births.

Doulas: Caring for Mothers Since History’s Birth

Traditionally and cross-culturally, supportive care of one or more women (often nonmedical professionals) during labour was commonplace.^[1] Continuous support during labour, usually from a woman outside of the birthing mother’s usual social circle, remains the norm today in many traditional cultures, and often extends to several days or weeks postpartum. Today, a doula is a support person who is trained to provide physical, emotional, and informational support to a birthing mother and her partner before, during, and after childbirth. Doulas provide support at hospital, birthing-centre, and home births, and often hold certificates and insurance reflecting their training. In most jurisdictions, doulas are not a regulated health profession, although licensed health professionals, such as massage therapists and naturopathic doctors, are increasingly becoming doulas to extend the care they are able to offer their patients at a truly meaningful time in their lives. In our own practice experience, hospital-based medical and nursing staff are increasingly embracing the presence of doulas at labour, delivery, and postpartum.

Birthplaces as Safe Spaces

Some women report satisfactory experiences with childbirth. Others experience significant stress and pain, and may opt for a C section due to fear, anxiety, exhaustion, or as a way to remove themselves from the experience of pain. The World Health Organization (WHO) recommends that no more than 15% of births should require C section delivery, while rates of surgical birth exceed 30–40% in many Western countries. If not medically necessary, C sections are more risky and costly than vaginal births. Due to the emotionally and physically intense nature of childbirth and the pain associated with the process, it is very common for women to feel discomfort, anxiety, or fear during labour. Recent research shows that having continuous support during childbirth is valuable in reducing fear and anxiety, promoting safe vaginal delivery, and reducing the risk of surgical birth (caesarean section or C section delivery).

Doulas and Birth Partners

Research demonstrates the value of continuous support during labour. The WHO recommends a pregnant women’s labour support should include someone whom she trusts and feels safe with, as this level of support is an important factor in women feeling satisfied with their birth experience. While most published research reflects labour support from a trained individual who is present unconditionally during labour and delivery who can attend to needs of the birthing mother, a recent study also looked at birth-support training for husbands. This birth-partner training for husbands was found to be of significant benefit to reducing the mother’s anxiety during childbirth.^[2] The greatest fear a pregnant woman have regarding childbirth is the associated pain and whether she can cope, with or without epidural anesthesia. Interestingly, it has been noted that the odds of having an epidural are reduced by 22%, and the duration of labour is shortened, with the presence of a birth partner.^[3] This suggests it is the continued physical and emotional support, coaching through rhythmic routines, and breathing exercises at each contraction which can reduce the body’s pain responses. A doula offers a variety of strategies and techniques for pain management during labour, that may include focused breathing, distraction pain stimulation, counter-pressure massage or hip squeeze, acupressure, or guided visualizations. These strategies are chosen on an individual basis and may be alternated from contraction to contraction as best suits the birthing mother. Expecting mothers can also benefit emotionally when these routines and strategies are initiated and practiced during pregnancy. Individual doulas and holistic prenatal classes offer this kind of training for expectant mothers and couples.

It Starts with a Healthy Birth

A healthy childbirth, free from trauma and with minimal nonmedically indicated interventions will not only have a positive effect on the birthing mother, but also for her baby. A study observing 300 doula-supported and 300 nondoula-supported women concluded that mothers supported by doulas had shorter labours, quicker rates of cervical dilation, and higher infant APGAR scores, which is quantitative assessment of a newborn within minutes of being born.^[4] Pooling results from several published studies, a systematic review concluded doula-assisted mothers were four times less likely to a have a low-birth-weight baby, two times less likely to experience a birth complication involving mother or baby, and were significantly more likely to initiate breast-feeding. Also mentioned was a correlation between the continuous communication and encouragement from a doula throughout a women’s pregnancy may have increased the birth mother’s confidence and self-efficacy, which can exert a positive influence on her pregnancy outcomes.^[5]

Mind-Body Connection

The mind-body connection has a powerful role on a woman’s perception of how her birth will unfold. Pregnant women are often flooded with negative stories of traumatic births from friends or even strangers, despite not welcoming or soliciting this information, and it can leave a lasting imprint on their perceptions of and expectations for childbirth. For instance, many women fear perineal tearing. While minor (first- or second-degree) tearing can happen, it is considered preferential to episiotomy, as natural tearing heals faster and more completely compared to incision. There is great anticipation of the lasting postpartum pain associated with possible third- or fourth-degree tears. There have been links connecting the presence of a doula to a reduction in both the severity of perineal tearing and the pain following labour.^[6] Perhaps it is having some sense of control and understanding of what’s to come during active labour, the support of a trained birth professional aiding the mother to perform effectual pushes during contractions, support for more controlled and restorative breathing, and an overall calmer atmosphere for the birth experience that helps to create a powerful positive effect on the physical outcomes a woman can experience postdelivery.

Postpartum Care

A doula’s presence can be transformative for health of mom and baby postpartum. Doula care has been shown to increase breast-feeding rates and contribute to a mother’s overall health after her baby is born. A study found a greater proportion of doula-supported mothers were breast-feeding and reported greater self-esteem, lower symptoms of depression, as well as higher regard for their babies and their ability for care for them at six weeks postpartum compared to the control group of nondoula-supported women.^[7]

Preventing Birth-Related Stress

All health-care providers would agree the most important birth outcome is a happy and healthy mother and baby. Mothers who experience birth-related trauma (physical or emotional) may be at increased risk of postpartum depression and may struggle with anxiety, bonding with the baby, or suffering other symptoms of posttraumatic stress that may last for a significant period following birth. Posttraumatic stress symptoms may also be triggered during, and negatively affect, subsequent pregnancies and births. Babies born by C section have an increased risk of developing allergies, asthma, and eczema in childhood due to not being inoculated with vaginal flora (good bacteria) at birth that influences their microbiome development through infancy and childhood. A study analyzing 2500 infants and data collected from physician-diagnosed atopic diseases found a correlation between caesarean delivery as an additional risk factor for wheezing and allergic food sensitivities up to two years of age, when C sections were done for nonmedically indicated reasons.^[8] A more recent study found women who had planned caesarean deliveries compared to vaginal deliveries were associated with an increased risk of asthma in children requiring hospital admission.^[9] A C section delivery is considered major abdominal surgery, and for postpartum mothers, recovery time can vary from six weeks to three months. Following a C section, there is an increased risk of developing infections, experiencing lasting chronic pain, or difficulties with breast-feeding. Women who have a C section can have more difficulty initiating breast-feeding, despite a strong desire to early in their pregnancy.

As you might imagine, some birth stories involve women having their power, personal control, and privacy taken away from them at one of the most vulnerable, yet strongest, moments in their lives. Sometimes, interventions including caesarean births are absolutely necessary. In other cases, interventions follow interventions in a cascade that may be preventable if women can feel supported in preparing for their births, managing pain, and understanding their options in advance. Having a doula at a birth can help women feel more comfortable, advocated for, supported, and less afraid. Doulas can help a woman understand and navigate any intervention that is being proposed to her during labour and delivery, so that the mother’s wishes are respected and an informed consent to any treatment or intervention may truly be given. It couldn’t be more clearly outlined in the literature that the presence of a birth-support person, such as a doula or the birthing mother’s trained partner, is beneficial to numerous birth outcomes including promoting safe vaginal delivery as well as the wellbeing of mother and baby. A doula-supported birth helps the birth mother increase feelings of personal control and comfort, which thus aids natural and normal birthing physiology.