For some reason, there are opposing sides in this issue and it’s hard even to approach the topic without raising the eyebrows of one side or the other. It’s not at all clear to me why there should have to be this division, but I’ll attempt a dispassionate consideration of the concept and then venture an opinion for what it’s worth…
First, a definition of sorts: a Doula is basically a labour coach -hopefully one with experience and knowledge that she can draw upon. I suspect the Doula originated in the mists of time because of the needs of women, usually in their first labour, who were beset by a bewildering number of myths, stories, and expectations all encased in a smothering blanket of pain. With no guide but the previously instilled rumours of hours of agony followed by horrid disfigurement if the baby was able to successfully negotiate the birth canal, the idea of a calming presence who could offer guidance and reassurance throughout the travail was appealing. Originally, no doubt, this would have been an older woman in the village who had some experience with labour, probably with a child or two of her own. She would therefore be able to approach childbirth with both compassion and empathy, her very presence reassuring, and her experience proof that there was not only and end to the process, but that a successful conclusion was possible. That the pain was worth it.
It’s still the same process, of course: hours of painful uterine contractions trying to force the baby down a previously untried birth canal; it still takes time for dilatation of the cervix, and descent of the presenting part -the usual definition of progress in labour; it still can go awry. And it’s all of these things but especially the last, that jeopardize the ability of even the bravest to cope.
Some things have changed, though. Effective pain relief is usually available if requested; monitoring of the labour and the baby’s heart rate help to determine if and when interference is warranted; intervention skills and techniques have improved. In most settings both mother and baby are probably safer now than they have ever been. Also, education about pregnancy and labour are widely available: there are prenatal classes, books and magazines full of helpful advice -albeit of sometimes dubious quality, and of course the ubiquitous internet with its plethora of opinions.
The point is, few women approach their delivery entirely ignorant of expectations and fears. I would submit that there is no tabula rasa for labour: everybody, even in direst poverty, has heard something about it; the Doula, if employed, should put those things into context for her client, dispel the harmful myths, provide reassurance and compassion. A friend might provide a similar service. Or a midwife. Or a nurse… We all need a hand to hold.
Why not just have the partner in there providing sustenance and support? That’s ideal if he (or she) can, but let’s face it, the partner is often just as excited and in turn dismayed and frustrated as the one in labour. They are, by and large, a unit with the same expectations and concerns. A knowledgeable outsider is probably better positioned to provide reassurance especially if the labour is long and difficult. A Doula should be a welcome addition to the team.
If I sound like I have reservations, it is because I do. The concept is great. Who would argue with support? A calm and reassured woman is likely to tolerate the problems of labour better than one who is beyond herself with worry and concern over various aspects of it that she cannot process or even understand in the circumstances. Pain and fatigue rarely dispose one to rational analyses. But it’s the experiential component that is often missing in the support -the objective assessment of the situation and the ability to change expectations accordingly. I have heard Doulas vociferously regurgitating their pre-labour instructions not to allow their client to ‘give in’ to the pain, despite its possible role in slowing the progress or tolerability of labour. I suspect that a more experienced coach might better understand that earlier, more naive instructions are not always sustainable in the light of changing circumstances. Many Doulas are sensitive to this and act accordingly -most Doulas, perhaps. But they are not nurses and shouldn’t try to function as such. They are there for support, not to interpret symptoms or read fetal heart rate monitors. They are not there to interfere with their client’s management.
In my center, there is a trained obstetrical nurse assigned on a one to one basis for each labouring patient. They can and do provide support and professional advice as part of their function. They are objective and compassionate, experienced and empathetic. And they are definitely patient advocates, making sure that any management decisions are in their patients’ best interests. Maybe their multiple roles should be more widely advertised. Maybe they are the best Doulas.
I realize that I am coming from a Western medical model, and that as a man, I am someone who could never truly understand what a woman experiences in labour, the support she needs, the encouragement that will help her achieve her goal. My views are biased by my own expectations, my model, my gender it’s true. I can’t escape them.
But I can advocate for safe and compassionate care that helps to ensure the well-being of both mother and baby. That minimizes unnecessary suffering. That strives for a rewarding experience free of fear or untimely intervention.
And so can the nurse… But wait, isn’t that what the Doula was hired to do?