A doula (//, also known as a labour coach and originating from the Ancient Greek word δούλη meaning female slave), is a nonmedical person who assists a woman before, during, or after childbirth, as well as her partner and/or family by providing information, physical assistance, and emotional support. The provision of continuous support during labour by doulas (as well as nurses, family, or friends) is associated with improved maternal and fetal health and a variety of other benefits.
A variety of organizations offer certification and training to doulas, though there is no oversight to their practice and the title can be used by anyone. In contrast to the goal of medical professionals (a safe childbirth), the goal of a doula is to ensure the mother feels safe and confident before, during, and after delivery. Doulas can be controversial within medical settings due to pressure on mothers to avoid medical interventions and pursue natural childbirth without an epidural or medically necessary caesarean sections.
History and etymology
The term "doula" was first used in a 1973 anthropological study conducted by Dana Raphael. Raphael suggested it was a widespread practice that a female of the same species be part of childbirth, and in human societies this was traditionally a role occupied by a family member or friend whose presence contributed to successful long-term breastfeeding. Raphael's derivation of the term is not clear, only describing it as coming from "Aristotle's time", and is defined as an Ancient Greek word δούλη meaning "female slave." Marshall Klaus and John Kennell, who conducted clinical trials on the medical outcomes of doula-attended births, adopted the term to refer to a person providing labor support.
The organization Doulas of North America (DONA, one of several in North America and internationally) registered 750 certified doulas in 1994, increasing to 5,842 in 2005. Between 1992 and 2004, DONA has provided training to approximately 25,000 people.
Types of support
The overall goal of a doula is for the mother to feel safe and comfortable, in contrast to the goal of doctors and nurses which is to ensure a safe delivery for mother and child. Doulas have no clinical role, duties or decision making, deferring instead to nurses or doctors.
The kinds of support provided during childbirth may include physical assistance and comfort (massage, maintaining a supporting posture or providing water), emotional support (providing company, encouragement or simply talking in a soothing tone of voice), information (advice or the progress of the childbirth), and acting as an advocate for the woman undergoing childbirth (suggesting options or supporting the woman's decisions to a medical team). Doulas may also be involved during pregnancy and after birth.
A doula is normally selected when the mother is approximately eight months pregnant. Continuity of support by the same person is thought to be an important aspect of the relationship between doula and mother. Doulas may be found in hospital- or community-based programs as well as private practice and may be reimbursed by insurance companies or out-of-pocket by clients. They are more popular among older, affluent parents in larger cities, and can charge up to $1,000 for three visits (before, during and after birth).
Continuous support during labour provided by doulas (along with variety of groups such as nurses, midwives, other hospital staff, partners, family or friends) have been associated with improved outcomes for both mothers and children. There is research to support the beneficial effects of doulas on both maternal and newborn or infant health, including shorter delivery, fewer caesarean sections and complications, the use of fewer medications and fetal extraction tools, improved Apgar scores, less time in neonatal intensive care units, positive psychological benefits for mothers, more satisfying birth experiences, and increased breastfeeding. Cross-country research on the effects of doulas on child birth and postnatal care is complicated by the variety of settings, cultures and medical systems of individual countries and characteristics of patients. These benefits appear to be contingent on the doula providing continuous rather than intermittent assistance, have some medical training and on the specific social and cultural setting within which their services are provided. This may be due to doulas providing intermittent assistance being experienced midwives who focused less on social support and more on medical aspects of delivery. Women with less education, lower incomes, less preparation for childbirth and those lacking social support may experience greater benefits from doula care than other groups.
However, some medical institutions have banned doula participation citing that doulas can "cross the line" during delivery, endangering mother and child. Some doula clients have also found their doulas carried personal agendas into the birthing room that were contrary to their wishes and a risk to their health. Though the American College of Obstetricians and Gynecologists has no official position on doulas, during an interview the ACOG's chairwoman of the academy’s committee on obstetric practice Sarah Kilpatrick, stated while doulas may be helpful there are some who try to "interfere with the medical aspect of delivery." Doulas may also oppose the use of any infant formula, medications or medical interventions during childbirth, refusing work with mothers who decide to have an epidural or otherwise undertake natural childbirth. Doulas acting beyond the role of social support and advocacy by providing medical advice should be addressed out of the presence of the patient, and professional associations have policies in place to address such issues.
Training and certification
There is a lack of standardization and oversight of doulas, with multiple organizations providing different courses with varying requirements. There is no formal or universally recognized certification process or training requirements, and anyone can refer to themselves as a doula. No academic credentials such as a college or university diploma, or high school equivalency are required. In contrast, in the United States a certified nurse-midwife can deliver a baby outside of a hospital and without doctor's assistance but is a conventionally trained nurse who has undergone an extra one to two years of training.
Doulas do not require or receive any medical training. In North America training generally takes the form of a two to three day seminar, and some experience with childbirth. Trainees may have hands-on practice with various techniques used during childbirth, including maternal positions and movements, relaxation and breathing exercises and other measures that could be used for comfort. Certification can occur through organizations at various levels (local, national or international) and requires positive evaluations from medical professionals including midwives. Certification may also require, in addition to attending a training course, time spent working or learning about maternity care and childbirth classes and possibly a written exam. Research also supports the use of female friends or relatives, after minimal training, as a low-cost alternative to professional doulas. Some doulas train through distance education.
Disputes between doctors, nurses and doulas have been described as a "turf battle", though it is also recognized that doulas and nurses can occupy complementary roles that provide opportunities for mutual learning and assistance. Some hospitals have created internal doula training programs to reduce conflict between doulas and medical staff.
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