In an attempt to improve the atmosphere of birth and gain the benefits of both birth rooms and the presence of doulas at birth, BC Women’s established an environment to support both.
I had been part of developing the birth room and the investigator of a study of the birth room at the Jewish General, so I was familiar with the model.32 As in many places across the country, hospitals were moving away from having labour in one room, warehousing babies in a large nursery (without rooming-in) and accommodating the mother for recovery in yet another room. “Musical maternal beds” were certainly going out of favour. In Vancouver, we were aware of the new trend and changed part of the hospital to single-room maternity care on the second floor, away from the operating rooms. A single nurse looked after the mother during her labour and birth, and she also looked after the newborn and mother in the same room until discharge.
As with any new development, there was resistance. We worked hard to encourage acceptance of the idea of single-room maternity care. The pediatricians and anaesthesiologists were initially skeptical or even against it. Some claimed that the time from the elevators on the second floor to the operating rooms on the first floor was too long. I pointed out that we were talking about five to seven minutes, whereas there were many places in BC where it was thirty minutes to hours for a Caesarean section—nevertheless with good outcomes. Eventually, the staff accepted, even liked, the concept.33
I will never forget a birth room experience in which a young Indigenous woman was labouring with her first birth. There were twelve people in the room, family and friends supporting her. As one was massaging the labouring mother, another was massaging the massager, and so on down the line. There was singing and chanting. When the labouring woman was finally too exhausted to carry on and the baby was not descending, I called for an anaesthesiologist to administer an epidural. The anaesthesiologist who arrived was a stand-in (locum), a man unfamiliar with such “nonsense.” “Everyone out. I cannot do my work with people looking over my shoulder,” he said. I negotiated to get down from twelve to six family members. The epidural was administered. The patient slept, woke up and birthed her baby. The selective use of epidurals is the way to go.
During my more than ten-year tenure as chief of the family practice department at BC Women’s and Children’s, a series of related issues evolved. The midwife development was big, but in parallel, the doula movement was developing throughout North America and eventually reached the hospital. Doulas are not responsible for the birth. The doctor or midwife is professionally responsible. The doula’s role is only to support the mother and not interfere with the health provider. I supported the doula movement from its start and have been on the board of Doulas of North America (DONA).
As the doula phenomenon evolved, it was not surprising that there was resistance from some quarters. Some obstetricians felt that doulas were usurping the role of the obstetrician. Even some nurses and midwives thought the same. Few providers had read the literature on the positive effect of doulas on key maternal and newborn outcomes. Some questioned the relevance for the typical North American environment, as almost all of the early doula studies took place in the developing world or inner-city settings.
As the doula movement reached the hospital floor, it became clear that all doulas were not the same. Why wouldn’t we expect that to be the case, as we know that all doctors or nurses are not the same? With trainees, I wrote about this issue and the conflicts that can occur when well-intentioned doulas run up against providers that the doulas know are not practising in an evidence-based way.34 These conflicts also emerged from our national study of the attitudes and beliefs of all caregivers. As well, it is clear that many women do not appreciate the potential importance of the doula role.35
Kathie Lindstrom was in charge of doula education at Douglas College. It was her role to train and monitor doulas in BC, but there are also other, less well-known doula organizations. It is even possible for a non-certified midwife in BC to avoid being arrested for practising midwifery without a licence by calling herself a doula, but that is another story.
Kathie and I put together a doula course for first-year medical, nursing and midwifery students. They learned interdisciplinary care and came to appreciate the other trainees’ skill sets. Although it was an elective course, it had an important positive effect on overall medical student training. When a doula-trained medical student reached their third-year OB/GYN clerkship, they already knew a great deal about normal birth. Typically, student clerks were encouraged to concentrate on births where there were problems, thereby creating a distorted view of birth. They spent lots of time assisting at Caesareans or complex instrumental births. But our doula-trained med students insisted on having a normal birth experience and some of their classmates saw their example and came to realize the importance of doulas and normal birth.
The doula model was then extended to a special ward for substance-using women. Again, medical, nursing and midwifery students took responsibility for the women and helped in the birth. The women often gave up drugs and kept their babies. Previously, the usual approach was to apprehend the baby. The woman would then repeat the process and come to the hospital again pregnant and drug-dependent. Dr. Ron Abrahams and members of the BC Women’s Family Practice Maternity Service deserve credit for changing a practice that was wrong and dangerous.