Why Hire a Doula

by Ashley Weeks Cart

doula

Sunny’s Fairy Godmother is expecting her first child this summer, and, after much thought and conversation, has decided to hire a doula. What I love and admire so much about my dear friend is that she not only heard and reacted to what she was learning from friends and fellow women about their birth experiences/needs, but in deciding to hire a doula, dove into the medical research and information that might verify or confirm some of what she was hearing anecdotally. She’s been able to validate so much of what I instinctively felt about the importance of a doula with compelling, fascinating, empowering evidence that doulas are, undoubtedly, a valuable asset during maternity, the birth experience, and postpartum life.

She is keeping a private blog for friends and family to follow in her journey, and this post that she wrote about why she hired a doula absolutely blew me away. It’s the kind of conversation doctors, insurance companies, and anyone working in or engaged with maternity, birth, obstetrics, labor, etc. should be having. Dellie herself is a doctor and I am so impressed with her level of thought and engagement with this topic. She has generously agreed to let me share her words here, as I think that it expands on many of the conversations I’ve had in this space and brings added value and meaning to that work. Many, many thanks to her! My girls are so fortunate to have smart, inspiring female role models like her in their lives.

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Over the past few weeks and months, friends and family have reached out with the same question, phrased in several different ways:

Why did you hire a doula?

I realized, with the repetition of this very welcome question, that my first post really did not do justice to explaining what has led Jeremy and me to hire Shayla. At the same time, I was letting myself down by forgetting skills and access that I utilized endlessly in the first trimester to better understand diagnostic screening options when it came to researching and understanding the significance of hiring a doula. Much of our decision was based upon gut feelings and the experiences, reports, and recommendations of a limited number of trusted people in our lives.

Then I found there is so much more to support our decision.

So, let me start at the beginning. No matter what happens, our number one goal is a safehealthy, ideally happy, Mom, Dad and baby to be together this summer. Underscoring safe and healthy. Neither Jeremy nor I has any preconceived idea that our experience “has” to go in a “certain” way. Even if we end up drafting ideas for a birth plan, it would be more of an exercise in focusing in on our own priorities and values than it would be a “plan” in any conventional sense. The process of labor, delivery, and childbirth is one that defies planning. It benefits from preparation, communication, and support. But I can be certain that we will be surprised. That we won’t really know what to expect until those hours and days arrive. That we will be challenged. That we won’t always know what is best, and that we will have to trust our instinct, communication skills, and the support of caregivers and loved ones to ensure that safe, healthy, and happy happen.

Moving up in the hierarchy of needs, we enter the world of values, experience, and preference. Some women truly fear labor. I have friends and acquaintances for whom the ideas of the potential pain, trauma, and physical hardship that come with vaginal childbirth are overwhelming and terrifying. There are women and families for whom those fears are so all-consuming that a maximal level of medical intervention, i.e. a planned cesarean section, is a welcome option. I admit in advance that I do not know what I will “want,” if there are options on the day we’re trying to bring this baby in to the world. I know that I want all medical options available, should they be necessary. I want my provider to be able to care for me and this little baby no matter what happens during labor and delivery. But, if everything goes smoothly, I also would prefer to minimize the level of medical intervention.

But what does minimizing medical intervention mean? To me, it means staying at home during labor as long as possible. Being able to walk, sit, move, shower, bathe, dance, and shift positions during labor for as long as possible. To use alternative methods outside of medical analgesia to manage painful contractions. To be as active a participant as is possible in bringing this baby into the world. To (myself) be able to focus on natural, normal, productive bodily processes, while allowing my care providers to be concentrating on data points. At each crossroads, whether it be administration of medication, use of monitoring, or addition or more staff to the room, to be able to say “yes” or “no,” and make that decision an informed, thoughtful one, not made in the heat of the moment. And not made under undue influence of a well-intentioned caregiver who might not have the same priorities as my family. It means being supported if we choose not to have an epidural. To minimize the chance of an unnecessary cesarean section or assisted birth. And after, g-d willing, that baby is born, to allow family contact, bonding, and establishment of breastfeeding to take precedence over “box-checking” medical procedures that can wait. To provide encouragement, support, and certainty, when saying “no” matches my and Jeremy’s value system, even if it feels difficult or like an inconvenience. Essentially, to maximize the chances of allowing the normal, if extremely challenging, process of childbirth to unfold in a way that is safe, healthy, and happy, while minimizing the chances of undue physical, mental, or emotional trauma.

So, how will a doula help us achieve these goals?

Here comes the science.

I actually started prepping this post some time ago, while searching for scientific evidence to use for a prepared-in-advance rebuttal to what will certainly be an initial denial for insurance coverage of doula fees. But I came up with much more than I expected, and much more data that spoke to me than I had anticipated. First, data to support the use of doulas dates back to at least 1991, when an article appeared in the Journal of the American Medical Association (JAMA), which is one of the top three international medical journals read widely by physicians of all different specialties. Although this article was not accessible in full text, it was a “randomized, controlled trial” (theoretically the highest level possible of evidence in medical literature) that compared three groups of “identical” (prospectively randomized) women giving birth: one control group, one group that was observed without doula support, and one group that had continuous support from a doula. The outcomes were simple: reduced rates of cesarean section (18% vs. 13% vs. 8%) and reduced rates of forceps-assisted deliveries. Similar trends were seen for other types of intervention: reduced rates of epidural anesthesia (55.3% vs. 22.6% vs. 7.8%); less use of oxytocin (used to “speed” contractions or promote the onset of productive contractions), shorter duration of labor (who wouldn’t be excited about shorter labor?), shorter infant hospitalization (again, a no-brainer to me), and less maternal fever.

An even earlier study in the New England Journal of Medicine (also among that triad of highly-touted medical journals) in 1980 showed a similar pattern when studying the impact of doula services on outcomes: shorter time from admission to delivery (8.8 vs. 19.3 hours), more awake hours after delivery, more maternal engagement (verbal and non-verbal) with infants, lower rates of cesarean section, and fewer perinatal “problems,” generally defined.

These studies from 1980 and 1991 set the stage for studies from that time until now that essentially confirm and further support all of these findings. Across cultures and socioeconomic groups (including countries outside of the U.S., including the wealthy and the poor, those with public insurance and those with private insurance), doulas have consistently been show to have statistically significant effects including: lower rates of cesarean section (particularly relevant when hospitals in the D.C. area have C-section rates ranging from 30-80%, even for low-risk women!), fewer epidurals, decreased use of any medical pain killers, decreased use of oxytocin and forcepsshorter labors (particularly shorter second phase of labor), higher APGARscores for babies, higher rates of successful breast feeding (and earlier/more “timely” milk let-down), and longer duration of successful breastfeeding.

Scientifically, hiring a doula is entirely in line with our family’s goals. If we can pay $1200 (or convince my insurance company to pay some, or all, of that cost) to reduce my chance of having a cesarean section by at least 40%, decrease the chances of needing an epidural or other medical analgesia, decrease the need for device-assisted delivery (and the possible adverse side effects of such instrumentation), and improve my ability to nurse effectively, sign me up. May well be the best $1200 we spend in this preparing-for-baby process. And that would be if the benefits of having a doula stopped with what I have listed above, but they don’t.

The scientific literature has gone a step further, looking at psychological outcomes of doula care. Although these measures are not as refined, and have not been replicated in as many systematic or randomized studies, doula support has been shown to result in, for mom: improved sense of security, less helplessness, less distress, higher self esteemhigher rates of “good” experiences with labor and sense of ability to “cope,” and higher perception of mom’s own “performance” and positive image of their bodies’ strength and ability. Again, sign me up. I would be ecstatic if, after delivering safely a healthy baby and staying healthy myself, I can also feel powerfulproud of my body, strong, and have a higher degree of self-esteem. I love thinking of labor and delivery through this lens: as a way to be empowered, inspired, and awe struck by the abilities of my body and this little baby. What a tremendous psycho-emotional outcome to which women should be able to look forward, instead of fear.

Although non-scientific, there are still many, many aspects of the importance of a doula’s support not delineated in the above research and detailed arguments. Time and time again we hear from friends and acquaintances how pivotal the support, reassurance, and creativity of their doulas meant to them. How it helped them be stronger as a family. Feel safe. Feel empowered. These stories are balanced by those of friends and acquaintances who didn’t work with doulas and have birth stories that make clear where the absence of a doula made the time more difficult, frightening, or disempowering than it should have been.

And at the end of the day, we hope and dream that the doula feels superfluous. That we are blessed with a safe, healthy, and happy delivery that requires minimal support, minimal intervention, and few difficult decisions. If that is the case, we will be so grateful that the money spent will seem a distant memory. And I bet I will still be grateful for the postpartum home-visit to support breast feeding and make sure that I am physically and emotionally healing and recovering from such a tremendous, challenging experience.

So, in one of my most epically-long posts thus far, I hope that I have been able to more articulately, thoroughly address the much-welcomed question of “Why a doula?”

Jeremy and I aim for a safe, healthy, happy, and intervention-minimizing (and I’ll take empowered if that comes, too!) childbirth experience. And through the preponderance of clinical evidence as well as anecdotal experience, hiring a doula is one of the best ways to increase our chances of achieving those goals.

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Addendum: It  surprises me quite a bit that, given all of the findings above, insurance companies still refuse to cover doula expenses. For a health care system obsessed with minimizing costs and “intervention,” why not invest the up-front money to support women in labor when there are so many positive medical advantages, and significant potential cost-savings?

On the same note, I think there is one important study notably absent from the canon described above: evaluating the impact of doula support on malpractice claims. It may simply be a hypothesis, but it would seem that a supportive third party who helps a patient and her family take an active role in decision-making for their care and improves physical and psycho-social outcomes would be extremely likely to reduce the probability of her client filing a law suit against other medical providers. I could be wrong, but it seems like an intuitive next step. Given the significant malpractice insurance costs associated with obstetrics, maybe someone will finally realize that it might be worth funding a trial that measures malpractice claim filings and settlements as one of its outcomes.

And maybe, just maybe, the option to work with a doula would then be accessible to more women and families who could benefit from their support, while the health system at large also benefits. Few health care conundrums are win-win-win for patients, providers, and insurers. But this one certainly could be.