Excerpt from Doulas, the Guardians of Natural Birth by Gabrielle Targett
In 2003 Adela Stockton a registered midwife, doula, childbirth educator and qualified homeopath from Edinburgh, wrote the following paper which appeared in the MIDIRS Midwifery Digest. The reason I have included this in my book is because Adela depicts so well through her writing, the role of the midwife VS the role of the doula within the hospital system. Who better than a qualified midwife and doula to make these comparisons and observations based on having worked on both sides of the fence, so to speak? Although Adela has worked as qualified midwife and doula on the other side of the world, the same intrinsic and fundamental problems exist with currently practising midwifery based hospitals, birth centres and private hospitals around the globe – a medical system that does not support their professional knowledge of natural birth, skills or training (both formal and independent), hence, the rise in the amount of doula’s being employed currently in countries where women are being exposed to high rates of intervention in childbirth which is considered the ‘norm’ but knowing by having a doula, they have a glimmer of hope of experiencing a natural birth within that system.
For the purpose of this paper, Adela explains the term ‘normal birth’ will be defined as true physiological labour and birth, without any methods of induction or augmentation and where a woman has not received any chemical drugs for pain management of any surgical incision.
Recent discussions as to whether the role of the doula may be seen as supportive to that of the midwife or merely a threat to the very art of midwifery, raises serious questions about the provision of maternity services in protecting normal birth. In a climate where medicalised childbirth prevails, more women are currently employing doulas to ensure one to one care during labour in an attempt to safeguard their chances of normal birth. Adela’s paper set out to exam the cause for this potential rise as the essential support person for a pregnant woman in preparation for labour and birth.
Role of the midwife vs the doula
The midwife can provide all the care necessary for a woman and her baby throughout pregnancy, birth and up to 28 days post-birth, as long as the condition of the woman and her baby remain within the normal limits. She is equipped to assess any deviation from the normal and to refer to the appropriate medical assistance, from which point she will continue to provide care under medical management. She acts to protect normal birth, to support women physically and emotionally through their childbirth experience using clinical knowledge and skills in education, counselling and health promotion. She stands as an advocate for women’s choice.
The doula provides emotional care and practical assistance to a woman and her partner during labour and during the pre – post natal period, depending on a doulas training. She can offer information, counsel and social support but is not trained to carry any clinical tasks. She may, however, be trained in other skills such as massage, reflexology, homeopathy or breastfeeding support. She is chosen and employed by the woman or couple to protect the memory of their birth experience, and to assist in their transition to parenthood. Her role derives from the birth support person who traditionally would have been (and still is, in some countries) the woman’s mother, sister, or friend. She also stands as an advocate through facilitating effective communication between the woman and her caregivers.
The decline of the midwife and the rise of the doula?
Rather than witness an increase presence of doulas within the current maternity care, greater resources spent on the midwifery services would allow for midwives to fully employ their skills as autonomous holistic practitioners, and in turn refute any role for the doula. Why indeed, if midwives are trained to be ‘fully with woman’, should women need a further support person during the time around childbirth?
For midwives with a passion in their hearts to make a real difference to the way women give birth, some may choose to practise independently where they will be able to achieve such aspirations.
For those in the National Health Service (NHS) system (in Australia the public and private hospitals) it is often a different story. Quickly disillusioned as their ‘hands on’ skills are persistently overruled by medical intervention and hospital politics, many feel obliged to surrender any desire to practise holistically in order to avoid being marginalised by their colleagues. Some continue to do what they can to support women’s choice piecemeal within a largely hostile environment, but others branch into education or give up their clinical practice entirely. Surely these practitioners are the very essence of what the system needs if it is to come anywhere near providing individualised women-centred care? When asked why they have left the profession, their reasons are clear: they refuse to remain complacent as the midwife becomes the obstetric nurse.
Are we witnessing the demise of midwifery?
It is perhaps not so much that midwives are bereft of the intention to protect normal birth, but more that their practice has been coerced from the reality of normal birth by the routines and protocols of the system. Beds dominate the birthing rooms, the recumbent position is encouraged for virginal examinations, continuous fetal monitoring is routinely preformed, and the rate of epidural anaesthesia is rising. Although the value of medical intervention in appropriate cases is recognised, the percentage of normal births, including those with an epidural, has fallen from 75% to 68% since 1997, with only 44% of women giving birth normally without epidural.
However insistent they are that they are supporting women’s choice and practising autonomously, midwives adhering to a protocol of two-to four hourly vaginal examinations are simply perpetuating the medical model of defensive practice. Setting up Syntocinon infusions or topping up epidurals ultimately remain procedures under medical management. Some student midwives are currently qualifying without the skills to support a woman through normal birth, having never looked after a labouring woman without an epidural in situ. These skills require physical and emotional commitment which is truly about being ‘with woman’, but such an essential part of midwifery care has largely been usurped by copious note-taking, checking of machinery and performing of invasive, often unnecessary procedures. This removal of focus from the woman has serious implications for midwifery practice, as noted in a recent study on one-to-one midwifery care, where the researchers found an actual reluctance amongst many midwives to emotionally support women during normal labour.
Doulas are mostly mothers themselves with a special interest in childbirth issues. Their work has been described as ‘mothering the mother’ and as ‘sisterly support’. The author suggests that the first of these echoes a relationship of co-dependency rather than the more equal footing and empowering bond of the second. The one aspect of the doula’s role that is certain, however, is her continuity of care. She is present for the woman or couple, having established their needs prenatally and agreed with them ways in which she might best support them during labour and with their new baby. There are no shift changes for her, and although this means she may work the duration of a long labour, she does not have to be ‘on duty’ again the following day.
Whereas postnatal midwifery care is consistently lacking in real time for listening, educating and guiding women in parenting skills or debriefing after birth, the doula may spend several hours a day for a period of six to eight weeks helping the new mother and baby, supporting breastfeeding, preparing meals and assisting with siblings. (In some cases where a doula maybe trained as a childbirth educator, she may also do all the pre birth education, informing couples from conception what their choices are, and build a rapport with a couple from the very beginning) At a human level, and as many midwives would also wish, the doula can negotiate her work with a flexibility that allows consideration for the needs of her own family as well, reflecting a partnership in care between client and carer.
Supporting evidence for doulas
Much of the research undertaken on the role of the doula has been done in the United States, where there exists a fragmented system of midwifery: nurse midwives, who care for the physical needs of women in the hospital and hand over the actual birth event to the doctor, or lay midwives who attend women birthing at home. Doulas thus entered the American childbearing arena in order to provide valuable emotional support to women giving birth in hospital. Further studies have been done in Guatemala, Canada, South Africa, Botswana and Mexico.
The evidence on the use of doulas shows a reduction in medical intervention during labour, with lower rates of caesarean section and other instrumental deliveries, and less need for epidural and opiate pain management. Better rates of breastfeeding have also been indicated the result of a doula attending a birth. Additional findings attributed to the support of the postnatal doula show improved parent/baby bonding and decreased incidence of postnatal depression.
Although there is simular evidence in support of one-to-one midwifery care, and Government recommendation promotes continuity of carer in an endeavour to decrease medical intervention during labour, recent research suggests this may not be happening.
“Women are giving birth not just in circumstances which are less than optimal emotionally. Some are giving birth in circumstances which are dangerous”.
As the evidence supports to the doula’s support being so vital to the labouring and postnatal women, could her role also be considered of some support to the midwife?
In theory, the midwife’s role does include that of the doula but, in practice, with the current constraints on the NHS (public and private hospital systems in Australia) resources, staff shortages and demoralisation of midwives, this is often far from reality. Apart from the radical minority practising within the large hospitals, working in small rural midwife/GP unit or midwife-led birthing centre is perhaps the nearest opportunity that a NHS midwife will get to autonomous holistic practise, and the nearest a childbearing woman will get to the excellent care that she deserves. Despite these pockets of good practice, where women are listened to and their wishes respected by midwives who feel fulfilled in their work, the majority of support for normality in childbirth is substandard. No amount of improvement to the maternity services is ever likely to accommodate true autonomous midwifery practices and women-centred care whilst the existing obstetric hierarchy persists.
Doulas as guardians of normal birth?
Traditionally, midwives have been heralded as the guardians of normal birth, but if they are no longer able, or even in some cases willing to provide women with the kind of support they need in order to have the best chance they have of a normal birth, some alternative must be found. Women who feel strongly about safeguarding normal birth are beginning to increase the volume in voicing their concerns; these include disenchanted midwives, pregnant women (who are employing doulas) and doulas themselves. Some doulas are indeed ex-midwives who have refused to become complicit in the obstetric nurse conspiracy and simply want to get on with the work of supporting the normal physiology of pregnancy, birth and the early days parenting. The organization Doula UK has been established, advised by a panel of childbirth practitioners including Sheila Kitzinger, to set standards for doula training, to evaluate the experience of practicing doula, to offer a forum for peer support and to provide information for pregnant women and their partners about local doulas and doula services. In the case of unsupported women or women who are in prison, some doula services are offered on a voluntary basis.
From the discussion raised within this text, it is clear that an increasing number of women are seeking to improve their chances of a normal birth but that they are not guaranteed to receive the support they need from their midwifery services. In a quest to avoid medical intervention during labour and lack of support during the postnatal period, many are making the informed choice to employ a doula as an essential part of their maternity care.
Where the midwifery profession has to a large extent been complacent in its surrender to obstetric nursing, perhaps the rise of the doula is the very issue that will expedite the creation of a formal distinction between midwife and obstetric nurse. The author suggests that in the meantime, midwives might be wise to show their support for women centred care by embracing the presence of doula colleagues. In this way they may also remain party to the safeguarding of normal birth.