The Doula

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?

Words and Names

Words are important, let’s face it; they help us address those most existential of all entities: concepts. They describe things, modify things, name things. Without them, we’d no doubt be reduced to gestures -limited descriptors at best. The richness that is reality would still be there, but unexpressed, identified perhaps, but somehow unrepresented. To an extent then, we, the world -everything- is partly  how it is described. Words are powerful.

By now I’m sure you’re wondering what all this has to do with women’s health. Why is an obstetrician pretending he’s a philosopher? Words again, you’ll notice… Well, when we name something -a process, a condition- it engenders a certain expectation. If you name an experience, the name comes to represent what was experienced. Pain comes to mind. Or laughter. We know how it felt to experience these and if someone were to suggest that they were going to occur again, we’d probably have a pretty good idea what to expect. It’s what names are for, after all. Of course, what we call pain might be different from what someone else experienced, but we know what that experience meant for us. We would be able differentiate it from, say, tingling, or maybe fatigue. And if someone were to say you were going to experience pain, the very word would likely engender an expectation of something fairly identifiable and even relatively specific.

Okay, how about ‘labour’? You are a woman in your second pregnancy; your first labour was terrible. Maybe the contractions were deemed inefficient despite their pain, and augmentation with oxytocin was necessary. It seemed slow and interminable, punctuated with frustrations you could never have anticipated, delays that seemed unnecessary, maybe even resulted in something you wanted to avoid: forceps perhaps, or a Caesarian section. You have all that to look forward to (backward to?) again.

But do you? Well, we use the same word for second labours, sixth labours, whatever. So with minor variations on the theme, you expect the same thing. You know what to expect; you know what mindless suffering awaits, and if there was some trouble with the actual birth process, you know it will repeat: you haven’t changed. Your pelvic measurements are the same and this baby measured even bigger than your last baby on the ultrasound you had a month ago. So if anything, it’s going to be worse. Your midwife or obstetrician has tried to reassure you that second labours are quicker, more efficient creatures than first labours. Different creatures, in fact. But despite the rhetoric, something tells you they’re wrong. After all it’s still called ‘labour’ isn’t it? And you know what that means; you’ve experienced ‘labour’…

So why don’t we call subsequent labours by a different word if they really are different? Like the apocryphal description of different kinds of snow by the Inuit using different words: not all snow is the same, obviously, so if you were to hear a different description, a different word, you would expect that what you were going to see and experience was going to be different as well. Words are powerful.

I tell this to my patients and they usually laugh, politely to be sure, but secure in their knowledge that it’s all going to turn out the same no matter what I say. For one thing, I’m a man, so how would I know? And for another, and an even more convincing certainty, if it were truly different, there would be a different word for it.

I have struggled for years to come up with another word, but alas, with no success -no Nobel Prize for advancement of women’s psychological health, no media attention whatsoever.  I suspect I’ve not even been particularly convincing, coming at it as I do from the ‘other side’… But Hope springs eternal, eh?

Any suggestions?