TACTILE AND EMOTIONAL SUPPORT DURING LABOR: THE DOULA

"Doula" is a Greek word meaning "a woman who helps other women." In the realm of contemporary perinatal care, the term has come to mean a caregiver who provides continuous physical, emotional and educational support to the mother before, during and just after childbirth. Doulas stay with the mother throughout labor, constantly assessing and responding to her needs.

A doula is a layperson, most often a woman, who understands the biological and medical processes involved in labor and obstetrics, and who usually has assisted in at least five or six deliveries under the supervision of another doula. Her training also provides her with knowledge of obstetrical interventions, so that she can explain them to the woman and her partner in the event they are needed.

Doulas typically function as a part of the "birthing team," serving as an adjunct to the midwife or the hospital obstetrical staff. Physicians and labor and delivery nurses may appreciate the doula's sustained attention to the mother, especially in hospitals where demands on the staff interfere with exclusive contact with the mother. The doula also serves a critical role in supporting and educating the woman's partner, enabling him or her to be as involved and as effective as possible in supporting the mother.

In the United States, most doulas work as independent providers hired by the expectant woman. (In fact, many hold full-time jobs outside the realm of health care.) Increasingly, managed care organizations are offering doula support as part of regular obstetrical care. In some European institutions, doula support is offered as a standard of care by midwives or nursing students (refer to "Institutionalized Use of Doulas," page 18). In many cultures, of course, the practice of a knowledgeable woman helping a mother in labor is not labeled anything as official as "doula" support; it is simply an ingrained, centuries-old custom.

Overall, the defining characteristic of doula-type care is continuous, uninterrupted, emotional and physical support of the woman for the duration of the labor and childbirth.²¹

THE ROLE OF TOUCH IN DOULA CARE

The doula can use many kinds of touch and massage, depending on what the mother finds helpful. Doulas may, for example, gently touch or stroke the mother's shoulder, hand or foot while offering reassurance. They regularly confirm what type of touch and body positions the mother is finding most beneficial, and alter their touch as needed.

As labor progresses, the doula may cradle the woman in her arms, wipe her brow, massage her and use other forms of touch as she educates her about what is happening to her body and in the birth of her child. She often instructs the partner or birth companion in doing the same, helping him or her to soothe the mother. Together, the doula and the partner may physically support the laboring mother in walking, sitting, leaning or squatting. To relieve back labor, the doula might use back rubs, hot cloths and pressure.

Studies have documented that a doula's touch and support leads to reduced pain-or, at the very least, the mother's perception of reduced pain. Controlled comparisons of women who received doula support with those who did not revealed that mothers in the "doula groups" reported significantly less labor pain.²²

The doula provides support after birth as well. Among other things, she may facilitate the parents' bonding with the child by encouraging close contact from the moment of birth, especially in the first hour.

CLINICAL BENEFITS OF DOULA SUPPORT

Within the past decade, a number of controlled studies have supported the use of doulas. Among these studies, two conducted in Guatemala City and one in Houston, Texas are of particular interest.^23,24,25 In all three, the investigators randomly assigned first-time mothers to doula support or no doula support. In comparisons between the doula and no-doula groups, the data were adjusted for interventions such as oxytocin and C-sections, making the presence or absence of a doula the only major difference in the labor environments of these two groups.

The defining characteristic of doula care is continuous, uninterrupted emotional and physical support of the woman throughout labor and childbirth.

Data from those studies, which demonstrate the benefits of doula support, are described below and summarized in Table 1 ²²

Length of Labor. The studies showed that doula support reduced labor time. Researchers were able to conclude that in spite of obstetrical methods of inducing and speeding up labor (e.g., artificial rupture of membranes, augmentation of contractions, forcep deliveries, C-sections), the mothers who received doula support were the ones with the shortest labors.

Vaginal Deliveries vs. C-sections. By conservative estimates, cesarean sections are performed in about 20 to 25 percent of U.S. births each year. In contrast, C-section rates among doula-assisted groups in these studies were lower: seven to eight percent.

Table 1.
Need for interventions in births without and with doulas²²

Epidural Anesthesia. In the Houston study, more than half of the women without a doula requested or required epidural anesthesia-compared with only eight percent in the doula group.

Oxytocin. In one Guatemalan study, only two percent of women who had a doula required oxytocin, a drug that increases the strength of contractions; 13 percent in the control group needed the drug. The Houston study documented significantly larger percentages in both groups. While oxytocin is helpful to some mothers, it causes contractions to become more forceful and painful-leading some women to need an epidural or other pain medication as a result of the oxytocin's effects.

Forceps. Although physicians use forceps much less often today than in the past two decades, this tool is still helpful in some deliveries, especially when epidurals have been administered.

The studies document forceps deliveries eight percent for doula-supported births, compared with 26 percent in the control group, a difference largely due to the more frequent use of epidural anesthesia in the nodoula groups.

Natural Deliveries. In the Houston study, 55 percent of the doula-supported women had natural vaginal deliveries-that is, delivery without C-section, anesthesia, oxytocin, medication or forceps-whereas only 12 percent of the women without doulas delivered naturally. In the words of the authors, "it is fascinating to reflect that the presence of one caring woman throughout labor resulted in such a large difference."²²

INSTITUTIONALIZED USE OF DOULAS: A CLINICAL MODEL

About 25 years ago, the National Maternity Hospital in Dublin, Ireland, introduced continuous emotional support on its labor and delivery units, in addition to a strict definition of the onset of labor. The results were impressive and so beneficial that the hospital established doula-type care-delivered by nurse-midwifery students-as a mainstay of its maternity services for all patients. Key results of this labor-support program include:

• a drop in the hospital's average length of labor to between a half to a third of what it had been before the program. Since the late 1980s, the mean length of labor for first-time mothers at the hospital has been slightly less than six hours. (The program also uses membrane rupture and oxytocin to assure a certain dilation rate.);
• a C-section rate of five to six percent that has been sustained for two decades;²² and
• a significantly increased patient census, facilitated in large part by the shorter labors, lack of complications and more rapid patient discharge following most of the births.²¹

BEYOND LABOR: BENEFITS TO MOTHER AND BABY AFTER BIRTH

The benefits of doula support do not end in the delivery room. Rather, benefits have been evident in both mother and infants long after the birth and the doula's support.

Mothers' first 24 hours. In the Guatemalan study, the researchers observed the women in the doula and nodoula groups through a one-way mirror for the first 25 minutes after the mothers left the delivery rooms. The ratings showed that the doula-supported mothers had more affectionate interaction with their infants, smiling, stroking and talking to their newborns more than did the no-doula mothers.²²

In addition, studies in Johannesburg, South Africa looked at 189 first-time mothers who had an untrained laywoman supporting them throughout labor. These female caregivers constantly used touch and verbal encouragement to comfort and reassure the wo men.^26,27

The new mothers who received doula care:

• reported less pain during childbirth at the one-day postpartum interview than they expected, while the control group mothers reported more discomfort; and
• reported less anxiety at 24 hours and 6 weeks postpartum (even though the groups had similar levels of anxiety before labor), had a better perception of how they had coped with the birth experience, and spent more time with their babies after birth.

The newborn at six weeks. Positive effects of doula support on the infant were also evident weeks after the doula's involvement was over.

Infant feeding. In the Johannesburg study, the doulasupported group showed a significantly higher incidence of breast-feeding and "on-demand" feeding. Also, 63 percent of the no-doula group experienced feeding problems with the newborn, while only 16 percent of the doula group experienced problems.²²

Table 2.
Feeding behavior at six weeks with and without doulas²²

Infant health. Although the infants had been similar in all respects at birth, mothers in the two groups from the Johannesburg study reported marked differences in the health of their babies at six weeks. The research did not determine whether these were perceptual or actual differences, but doula care during labor and delivery clearly instilled some attitudinal or physical advantages to mother or child, or both. Some of the differences may be related to the higher incidence of breast-feeding in the doula group.²²

Table 3.
Infant health problems at six weeks after birth with and without doulas²²

Mother-infant bonding. Mothers in the doula group reported spending 1.7 hours a week away from their babies, as opposed to 6.6 hours reported by the nodoula group. The doula-group mothers reported an average of 2.9 days to develop a relationship with the baby, compared to 9.8 days for the other group of mothers. The results suggest that mothers in the doula group were more available and better able to form an attachment with their newborns.²²

Mothers' emotional state. Psychological tests in the Johannesburg study found significantly less anxiety, fewer signs of depression and a higher level of self-esteem in the doula-group mothers, suggesting that, among other things, they are less likely to suffer postpartum depression. Mothers who feel better about themselves are also more likely to provide a nurturing environment for their infants.

Researchers also reported that doula-supported mothers felt a great increase in satisfaction with their partner after the birth of the baby. Mothers who did not receive doula support did not express this degree of satisfaction. In a variety of areas, the doula-supported mothers' perceptions of themselves, their babies and their partners were clearly more favorable.²²

MECHANISM OF ACTION: WHY DOES DOULA SUPPORT WORK?

The mechanism of action by which doula care produces its positive effects is unknown but is assumed to involve the combined influences of the doula's physical and psychological interventions.

Some investigators theorize that the catechol-amine stress hormones adrenalin and noradrenalin cause the labor of many mothers to slow down, making complications more likely and the labor experience more taxing and stressful. By calming the patient through touch, reassurance and relaxation, however, the doula may alleviate the woman's fear and apprehension and, in turn, help to moderate the hormonally mediated stress reactions, ultimately lessening the need for medical intervention and shortening the labor.

IMPLICATIONS FOR HEALTHCARE COSTS

When Klaus et al. conducted a meta-analysis of six randomized doula studies, they reached the conclusion that the presence of a doula reduces the overall cesarean rate by 50 percent, length of labor by 25 percent, oxytocin use by 40 percent, pain medication by 30 percent, the need for forceps by 40 percent, and request for epidurals by 60 percent.

These results indicate the potential financial benefits of doula services, on both institutional and national levels. If widespread use of doula services were to cut the number of cesarean sections in the U.S. by half and reduce epidural use as well, savings in the nation's medical-care costs would be an estimated $1.3-1.6 billion annually.²¹