Leza Besemann first heard of doulas—women whose job is to provide continuous emotional support during labor, but who are not medical nurses—at a natural childbirthing class in the early 2000s, when she was 30 and preparing to have her first baby. “As soon as my husband and I heard about the role of doulas, we knew it was something we wanted to do,” Besemann said. She has since given birth to four children with the help of a doula, whom she says is “like a member of the family.”
According to DONA International, one of the oldest and largest doula training and certification organizations, a birth doula provides emotional support during labor, employs physical comfort measures (like massage or repositioning) and facilitates communication between medical staff and the laboring woman. "For us it was a matter of having someone there to run interference, so the doula could help us communicate to the staff what we wanted, while my husband and I could just focus on the labor," said Besemann.
Typically, a birth doula will meet with her client at least once before the birth to discuss her birth plan, be present for the entire duration of the labor, however long that may be, and meet with the client a few days later. A postpartum doula, on the other hand, is someone that supports the mother in the first few weeks or months after birth—dubbed the "fourth trimester"—for an hourly wage, assisting with newborn care, helping out around the house, providing companionship and educating the mother on "infant feeding, emotional and physical recovery from birth, infant soothing, and coping skills for new parents." A birth doula also differs from a midwife, which is a childbirth professional (in the U.S., normally a Certified Nurse Midwife) trained to assist in the actual labor and birth, referring the mother to a medical doctor only if a serious complication arises. Brith doulas also typically work with women who are giving birth with an obstetrician, since midwives tend to have assistants that provide similar care to that of a doula.
While the practice of hiring birth doulas, whose services can cost anywhere from $500 to $2,000 out of pocket, has typically been done by a fraction of middle- to upper-class professional women in their 30s, a recent nationwide survey by Listening to Mothers indicates that the percentage of women hiring doulas for labor may have risen in recent years, from three percent of births in 2006 to six percent last year. Anecdotal evidence also suggests a positive trend, with more doula training and certification programs cropping up around the country, more women getting certified as doulas and more doula volunteer organizations that provide doula care at minimal or no cost.
The issue is likely to increase in visibility as some states pass legislation to cover doula care through Medicaid and other states consider following suit. In Oregon for example, doula services can be reimbursed through Medicaid since doulas are considered non-traditional health workers. In July of next year, Minnesota will begin Medicaid reimbursements for doula care as part of its Omnibus Health Bill.
But does the research on the efficacy of round-the-clock empathy during labor justify splurging on a privately hired doula or covering the cost through state Medicaid programs?
“There’s really good data documenting that continuous emotional labor support leads to positive birth outcomes, with the strongest effects coming from someone who has specialized training and who is not a family member, friend, or employee of the hospital—meaning someone like a doula,” says Katy Backes Kozhimannil, an Assistant Professor at the Division of Health Policy and Management at the University of Minnesota. In the 2012 study she’s referring to, women who had continuous support experienced shorter labors; were more likely to have spontaneous vaginal births; and were less likely to report dissatisfaction, have a caesarean section, or a have baby with a low five-minute Apgar score, an indication of a newborn's health (based on appearance, pulse, grimace/cry, activity and respiration) that ranges from zero to 10.
In Kozhimannil’s own research from earlier this year, she and her colleagues compared birth outcomes of Minnesota Medicaid recipients who received doula labor support and prenatal education with birth outcomes from the national Medicaid population in an attempt to estimate potential cost-savings for Medicaid populations.
Though the research indicated that women with doula support were 40 percent less likely to have a caesarean section, they also concluded that states would likely see Medicaid cost-savings with a doula reimbursement rate of $100 to $300, which is, at least for now, well below the going rate of a basic doula package.
Christine Morton, whose book on doulas in the United States will be published next year, is a proponent of doula care. However, she warns of overstating their ability to influence birth outcomes.
“The concern is whether those small programs and their results will be maintained in other contexts. There are multiple factors that affect C-section rates at particular facilities. We need to be cautious when we talk about the least medically-oriented person on the maternity care team being able to change a very complex outcome, irrespective of the context,” she said.
Morton also points out the organizational diversity within the doula community. While more people are getting certified through various doula training and certification organizations like DONA, anyone can simply refer to himself or herself a doula. Though several people interviewed for this story emphasized that certification does not necessarily create an effective doula, across-the-board industry standards remain to be set.
And doulas are not without their critics. Some argue that doulas are an unnecessary financial cost at least, and can disrupt the patient’s relationship with medical professionals, leading to complications, at worst. An article published in the Wall Street Journal in 2004 cited instances in which a doula delayed a needed caesarean section or convinced her client that she did not yet need to go to the hospital.
Dr. Katarina Lanner-Cusin, Medical Director of Women’s services at the Alta Bates Summit Medical Center in Berkeley and Oakland, says that in her experience, the relationship between medical personnel and doulas can become contentious.
Viji Natarajan, who has worked as a doula in the San Francisco Bay Area for several years, said, “I’ve heard of stories of doulas getting too confrontational with medical staff and getting kicked out of the delivery room. I think if a doula is too aggressive, lines get drawn by medical professionals who will say, ‘Hey, I’m in charge of this person's care and you’re nobody here.’” Natarajan says the role of the doula should be to establish a calm and healthy environment in which a woman achieves her birthing goals or, short of that, understands the changes to her birth plan and everything happening in the delivery room.
In order to avoid any conflict between doulas and medical staff, some hospitals have established policies for working with doulas.
Alta Bates established a policy in the last few years, for example, and requires that all labor coaches and patients agree to it. The policy explicitly states that doulas are not permitted to interfere with medical treatment, perform medical tasks, offer medical advice or make decisions on behalf of their clients.
While hospital guidelines certainly prevent complications, they might also be why doulas are in such high demand. Rachel Shaw, who has worked as a doula for 10 years, points to the complex nature of hospital protocols as the principal reason why more women are seeking doula support during labor.
“The birth climate is getting increasingly hard to navigate and it’s becoming more difficult for women to learn about pregnancy and labor. It’s hard for them to figure out how to ask for what they want and need, because the birth protocols are so specific,” Shaw said. “A doula can advocate for their clients and help women better understand that system.”