A Doula (//), provides continuous emotional and practical support, for mothers and couples, through pregnancy, birth and immediately postpartum, also providing flexible practical and emotional support postnatally for new mothers and families in their own homes. Doulas are usually experienced women and mothers who have undertaken a doula preparation course. Doulas support families from all ethnic, religious, social backgrounds, including couples and single parents, same sex parents, low income families and executives, students, lawyers, midwives and doctors etc. Doulas spend time building a relationship with the families they are supporting. They offer space and time for parents to discuss and reflect upon their own situation, their needs, past experiences and options in childbirth to enable them to move towards a positive experience. Doulas are not there to take the place of the family or partner during a birth, unless parental choice, circumstances or cultural pressures mean that the mother’s partner is unable to be with her during labour and birth. Doulas do not take a clinical role, they work alongside their client’s care providers, supporting clients in their own choices. At all times a doula is led only by her client’s wishes and does not make specific recommendations, though may signpost to evidence-based resources and information.
History and etymology
The term doula was first used in a 1969 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 modern doula started out as an American phenomenon, but has later to some degree spilt over to the Anglophone world and, after the turn of the millennium, to other 1st world nations.
Types of support
The overall goal of a doula is for the mother to feel safe and comfortable, enhancing 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.
A birth doula is also called a labor doula. 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), 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 (postnatal care).
Most doula-client relationships begin a few months before the baby is due. Before the labor, the doula and the family can develop a relationship where the mother and her partner feel free to ask questions and express fears and concerns, and where the mother can take an active role in creating a birth plan. 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. Because insurance companies typically do not cover the cost of hiring a doula, they are more popular among middle- and upper-class parents.
Postpartum doulas provide help and support in the first weeks after becoming a mother. The same person often provides both birth doula and postpartum doula services. They may provide physical support, such as meal preparation and light household tidying, or fill in when a new mother needs a break. They also provide emotional support and companionship by encouraging a mother when she might be feeling overwhelmed.
An antepartum doula provides help and support to a mother who has been put on bed rest or is experiencing a high risk-pregnancy. Emotional, physical and practical support can be provided by an antepartum doula in these circumstances.
A family life doula provides help and support to an entire family. Occasionally confused with nannies, family life doulas are ongoing, long-term sources of support within a family structure. They fulfill tasks similar to those of postpartum doulas. Additionally, they care for children while providing emotional support, encouragement, companionship, and, if requested, guidance to new mothers. A family life doula can play a key role in lowering a family's stress so parents are able to focus on thriving in their careers while growing together as a parenting team at home.
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, 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's providing continuous rather than intermittent assistance, have some medical training and on the specific social and cultural setting within which their services are provided. 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." In March 2014, the ACOG put out a Consensus Statement titled "Safe Prevention of Primary Cesarean Delivery" in which it said, "Increasing women’s access to nonmedical interventions during labor, such as continuous labor support, also has been shown to reduce cesarean birth rates."  Doulas provide information about medications or medical interventions during childbirth and help the family decide if her practice fits the family's birth wishes such as those who decide to have an epidural or otherwise do not undertake natural childbirth. Doulas acting beyond the role of social support and advocacy by providing medical advice, practicing outside their scope of practice may be acting as a traditional birth attendant.
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.
Being a doula does not specifically require any medical training, although it is not uncommon for doulas to have received certification or medical training of some kind. 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 some require positive evaluations from medical professionals. 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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