‘During labour my husband was wonderful, but of course the things that worried me, worried him too. The midwife was fantastic, but she was also looking after other women. There were times during the birth when we felt very alone indeed, and scared, and just didn’t know what to do.’
CAT, 30, MOTHER OF DYLAN (1)
Throughout this book we’ve banged on about the vital role of support – practical and emotional – during childbirth. In Chapter 5: Your Options we showed you how to choose and work well with your medical team. You’re probably intending to rely on your baby’s father for other support during labour. This is no bad thing. If he’s well prepared he’ll be indispensable. But it’s worth thinking for a moment about his limitations. He’s unlikely to be any more experienced than you are when it comes to childbirth. And even if he happens to be an obstetric genius, he’s going to be watching YOU, the love of his life, in pain: he may not be as calm, collected and rational as you’d like to think. This is where a third person – preferably a woman who has given birth herself – can be a huge asset.
There is now good, solid, scientific evidence that having a non-medically trained woman supporting you during childbirth is beneficial. In 2003, a comprehensive review published by the Cochrane Library, the biggest source of evidence-based healthcare in the world, concluded that having a doula or other non-medically trained woman present at the birth significantly raises your chances of having a straightforward, manageable experience of childbirth.1 The review examined 15 research trials involving almost 13,000 women giving birth and found that those who had continuous support from someone who was not a hospital staff member throughout labour needed less pain relief, had fewer caesareans and reported a far more positive experience than those who were cared for by hospital midwives alone.
None of this should diminish your partner’s role. John could not have been more vital or supportive to me during all three of my labours. But, particularly first time around when the birth didn’t go smoothly, I was acutely aware that he didn’t know any more about getting babies out than I did. During a particularly tough period in Izzie’s birth, I remember John muttering lovingly: ‘It’s all going really well,’ and me thinking, quite clearly ‘What the f*** do you know about it?’. I may have even said this. Possibly quite loudly. In short, the things that threaten to freak you out during the birth may well freak him out too (possibly even more). There may also be times when he’s genuinely worried for your safety and this can be far from reassuring. When I got an epidural, during Izzie’s birth, we were left with a trainee midwife. I began to shake uncontrollably. Neither John, nor I, nor the trainee midwife had any idea that such shaking can be a side-effect of an epidural. John’s calm words, though I appreciated them, couldn’t quite mask the look of panic in his eye. It would certainly have helped us at this point to have someone there whose job it was to reassure us and help us to cope.
Traditionally, of course, this is the midwife’s job. A good midwife will absolutely give you a great deal of encouragement, reassurance and bolstering. But there’s a huge national midwife shortage in the UK today. Continuous one-to-one care is just not the reality for most of us: your midwife (who you may never have met before you arrive at the hospital) is unlikely to be with you throughout your entire labour. There’ll be shift changes, she’ll probably be caring for one or more other women at the same time, and (particularly if there are complications) she may have to juggle your emotional needs with the demands of her medical role. She can’t, for instance, be mopping your brow, whispering in your ear and keeping your husband hydrated if she’s unhooking the umbilical cord from your baby’s neck.
A doula or an experienced woman friend, on the other hand, has no medical role. She can be next to you whatever’s going on ‘down there’. When you and your partner are both wobbling, and the midwife is busy with the more technical side of things, it can be immeasurably beneficial to have a sane, calm, and most of all credible voice by your side going: ‘This is normal, this is safe, you are doing well.’ When you’re exhausted and labour seems to be going nowhere, and the midwife is helping the woman in the next-door room, it can be incredibly helpful to have someone with you who knows lots of ways to get labour going; someone who knows about positions and techniques that will maximise the efficiency of your contractions, and minimise the pain. A good doula can also make an unexpected caesarean or an instrumental birth acceptable and manageable. It’s no wonder many women say that hiring a doula was the best decision they made.
Of course, not all of us can hire one. Doulas are fast catching on in the UK (they’ve been around a while in the States) but it’s early days, and in some parts of the country it can still be hard to find one. Doulas can also be expensive. But if you think you couldn’t find or afford one don’t skip this chapter. There are ways round the logistical difficulties and even if you don’t end up hiring one, you may decide to have a female relative or friend with you and your partner at the birth (if you do, get her to read this chapter!). A female ‘support person’ even if she’s not a trained doula can be an absolute godsend in labour. We’ll explain here what your lovely lady – whoever she is – can learn from doulas about really helping you in labour.
The word ‘doula’ comes from the Greek word for ‘woman’s servant’. Doulas are women who are trained to give you emotional and practical support during pregnancy, birth, and sometimes after the birth. They are not medical professionals. Having a doula is hardly a new idea: for centuries women were attended in labour by a female relative – their mother, sister, cousin – as well as the midwives. In many cultures this still happens but in Britain (and indeed, much of Europe and the USA), the tradition has dwindled, probably because medicated hospital birth is now the norm. The recent rise in doula popularity in the UK shows we’re not happy with this situation: we’re starting to realise there are things we can do to get a better birth – if we take the initiative.
You may encounter two different kinds of doula: a ‘birth doula’, specially trained to give you support during childbirth, and a ‘postnatal doula’, trained to support you after the birth (she’ll know about mother and newborn care, be able to give breastfeeding support and advice and help with cooking, childcare, errands and light cleaning). Many doulas (Julia is one) are trained in both birth and postnatal care.
Most birth doulas will meet with you two or three times before the birth and will be there consistently for telephone/email support in the run up to it. When you go into labour your birth doula will usually come to your house. Then, when you’re ready, she’ll go to the hospital with you, and will stay with you until you’re settled with your baby after the birth. Once you come home, she’ll probably see you once or twice in the first few weeks but if you want to discuss the birth at any time in the future, she’ll usually be there for you.
A BIRTH DOULA (OR A GOOD FRIEND):
She should NEVER:
‘Attending a birth is amazing,’ says Shona, a doula for five years. ‘You’re so exhausted you could weep, you haven’t gone to the loo for nine hours even though your bladder’s bursting, and there is still no place in the world you’d rather be.’ Most doulas are motivated by a passion for childbirth. They usually have a strong belief that women who are supported properly can have a far more positive experience than they otherwise might. They are really interested in the emotional side of childbirth, and how it can affect your overall experience. Jennifer Nunn, former president of DONA International (the biggest US-based doula organisation) has been in maternity care since 1989. She used to be a midwife but felt that while ‘the physical factors of labour are supposedly understood, the emotional aspect has been understated. As a midwife I saw doulas as being the one thing that could change maternity care; whispering to the mother, not telling her what to do, but empowering her…. .[this is why] I opted for the subtle empowerment of being a doula’.
Labour support professional, labour companion, birth partner, birth companion are all synonyms of ‘birth doula’.
The short answer is simple: because researchers have found the birth is more likely to be straightforward if you do. One seminal study2 looked at the effectiveness of doulas by comparing three groups of first time mothers: those who received active doula support, those who did not, and those who were only observed by a doula. The women who received doula support had fewer epidurals, used fewer drugs to speed up labour, had fewer admissions to neonatal intensive care, shorter labours and fewer surgical deliveries (indeed, the women who were simply observed, also had reduced rates of intervention, pain, epidurals and complications).
Beyond all this data, the main reason to hire a doula is that by doing so your birth should be a significantly more positive experience, whatever happens.
This testimonial sums up the advantages brilliantly3:
Ava was finally born about 22 hrs after the doula had arrived at our home……she must have been exhausted but it didn’t show. Having the doula there as added support really was the best decision my husband and I made during pregnancy… despite ending up in hospital with an epidural and eventually ventouse, I feel very positive about the decisions we made and the overall experience. I felt completely supported and my husband felt supported too…. .I would recommend anyone to consider having a doula – it may feel like an extravagance to some but it really does make a difference to what is one of the most scary, amazing experiences of our lives.’
The best place to start is with Doula UK (DUK), a non-profit organisation for doulas and those who want to find them. Most doulas are currently hired by middle class, professional working women, generally in the London and surrounding areas. But this does not have to be the case. Doulas are springing up all over the country. And doulas in training will take on clients for little or no fee. Many doulas also have a sliding scale of fees, depending on what you can pay. Always ask, if money is a problem. Don’t think a doula is just an indulgence for posh Islington types.
In the us, the ‘doula movement’ is far more substantial and structured than it is here (though we’re getting there). There are two major organisations: DONA International and Association of Labor Assistants and Childbirth Educators (ALACE). DONA has recently set up training in Britain.
Many people have funny ideas about what a doula is for. Here are some of them.
As Julia explains:
‘A doula is not a barrier between you and the medical staff. At times she might be a buffer certainly – helping you finish a contraction before you have to speak to a new doctor, for instance – but not a barrier from medical counsel.’
‘My birth was very high tech, very high risk, with many complications. I don’t remember it….[but] my doula was wonderful. She attended my emergency C-section. She was the only one who was there, out of 25 people, solely to recognise that it was a birth of three people and simply witness it. I was practically unconscious and Charles was trying to keep track of three babies, one obviously very sick indeed. My doula wrote my birth story and it’s the only thing I have. She also took a few pictures and they are such a gift. Don’t underestimate what a doula can do, even if it’s not about labour.’
Your doula, then, rather than getting between you, your man and your baby, or ‘robbing’ him of his role in the birth, will actually help him to stay useful, calm and genuinely supportive. She’ll make sure he pees, eats, drinks and stays on top of the great emotional wave that is the birth of his child. She’ll make sure he won’t pass out, fall asleep or panic when you need him most. She’ll show him how to give you comfort if he’s uncertain about what to do. She’ll make sure he understands what’s going on so he’s not scared. She’ll reassure him, so he can reassure you. She’ll prevent him from feeling, as many men do, that he is redundant, or helpless or unable to comfort you. In short, a birth doula can transform a man’s experience of his baby’s arrival.
My husband John initially felt hostile at the idea of a doula. His first reaction was ‘so what will my job be then?’ However, once we hired Julia, he quickly realised that she was an asset:
‘Having doulas at the births of our second and third babies was a totally different experience for me. With Izzie, our first, we didn’t have a doula. The childbirth classes all made me feel that the main way I could be helpful during the birth would be to become knowledgeable and somehow advocate for Lucy. In the event I realised I wasn’t knowledgeable at all – that whole idea felt like a complete con – I felt intimidated, panicked, nervous and useless most of the time. With our second baby, Julia worked with us a lot during the pregnancy to unpick Lucy’s fears. This helped me realise that what Lucy needed most of all was for me to be reassuring, solid, calm and loving. This felt like a huge release: all that other stuff was not my job – I didn’t need to be second-guessing doctors or asking pertinent questions. Julia also made sure that we were both at all the meetings with her during the pregnancy – had she not done this I’d have felt like a spare part.’
As Julia puts it:
‘I have had women come to me saying they’ve called other doulas who ‘wouldn’t DO’ hospital births. We are hired to comfort the labouring mother and her partner, and to stick to her birth plan. A good doula should attend your birth whether it’s at home or in the hospital. Her job is to help you have the birth you want – as simple as that. She may tactfully open your eyes to certain scenarios and options you had not previously considered. But ultimately, the choice about where and how you give birth must be yours. Women can find satisfaction from any scenario. We know that we’re useful to any woman who wants to hire us, regardless of her birth plan.’
A doula should not interfere with the medical side of things, but at times she can be a great a buffer between you and a difficult situation with hospital staff. Valerie, a doula from Kent says:
‘I remember one dad – Richard, expecting his first child – who was not pleased with the fact that the midwife kept coming in the room unable to remember anything, as if she hadn’t read the notes. He would have shouted at her but he said to me “I am leaving – Valerie please deal with her and call me in a little while”…. He needed some fresh air!’
‘Women through the centuries have had other women with them while they are giving birth. Not specially trained women, just women who have had babies and can be there with them during labour,’ says Sheila Kitzinger, author and social anthropologist of birth, who founded Holloway Birth Companions. It may not be possible – for financial or geographical reasons – for you to hire a trained and experienced doula. You may decide, having weighed it up and even spoken to a few doulas, that you’d rather not hire one. This does not mean you should abandon the idea of having another woman with you in labour. Having a carefully chosen and well-prepared female friend or relative at the birth is also very likely to increase your chances of coping. But you do have to choose her carefully. And prepare her well. Here are some important issues you should explore before you invite your mother, sister or best friend to show up at the hospital with her camcorder.
Your mother may have been a paragon of good sense when calming your wedding jitters but seeing her baby having a baby could do her head in. Your best friend may have three kids, but the fact that she wants to leave her husband and marry her anaesthetist might inhibit her ability to support your waterbirth plans. Here are a few things to consider when choosing your support.
SPECTATOR SPORTS AND WHY BIRTH ISN’T ONE | The last thing you need, in the labour room, is a spectator. Some childbirth experts argue that we give birth more smoothly if we have as much privacy as possible (see Chapter 3 Fear and Pain). Obstetrician Michel Odent is the best-known proponent of this (indeed, he believes we need to ‘mammalianise’ childbirth: in other words, get back to our animal roots and give birth in relative privacy). Odent argues that anything which stimulates the neocortex of a labouring woman can slow or impede their ability to give birth. Even a video camera, he claims, can be detrimental to a labouring woman. ‘A feeling of being observed,’ he writes, ‘is another type of neocortical stimulation. The physiological response to the presence of an observer has been scientifically studied. In fact, it is common knowledge that we all feel different when we know we are being observed.’4
Of course, your birth may not progress smoothly and you may need or choose to have medical interventions. If this happens, you may not have privacy and calm: unfamiliar faces can quickly start appearing, lights may go on. Having a trusted, reassuring person by your side at this point can allow you to block out the hubbub. If your friend is making you nervous or self-conscious, this won’t work. You may think you can’t possibly be inhibited by the presence of someone you know well and this may be true – particularly if they are helping you to feel safe, unbothered, secure, reassured. But if you feel that person is watching you anxiously or worst still judgmentally, if they’re interfering or making unhelpful comments then their presence could well nudge you in the opposite direction.
YOUR SUPPORT PERSON SHOULD BE:
Here are a few questions to help you decide whether she can do this:
‘I once attended a birth that was going well,’ says Jennifer Nunn. ‘The woman was in late active labour, concentrating beautifully and it was all smooth sailing ahead: until her best friend barged in and said, during a contraction in a loud voice, ‘Why don’t you have an epidural now?’ That friend had had a very difficult birth, resulting in a very difficult caesarean. Now she was passing her birth issues on to a well-progressing labour.’
Exploring her birth baggage is, then, a vital part of working out if she’ll be a positive addition to your labour.
If you’re happy with the answers to these questions then the next step is to give her an idea of the things she can do for you.
A GOOD LABOUR SUPPORT PERSON WILL
FIVE WAYS TO HELP HER TO HELP YOU
One of the most crucial aspects of a doula’s role is to help you to feel relatively in control of anything that needs to be ‘done’ to you during the birth. During labour you might be faced with choices about medical interventions or procedures. If you’re being bombarded with contractions, haven’t slept for 24 hours and are at the end of your tether, it can be hard to weigh things up and make rational choices. This is where an experienced doula can be helpful. She can help you to understand what’s going on and to feel as if you are being properly consulted. You don’t have to be a medical expert to do this. You just have to be rational and calm enough to ask why something needs doing, what the pros and cons are, and what the alternatives are. Your baby’s father may well be (on some level) too frazzled and anxious to do this effectively. A doula, on the other hand, is less emotionally involved. This is part of her job. Studies have shown that feeling consulted and respected, and understanding the reasons for any procedure can make your experience of childbirth more positive, regardless of the circumstances.
A doula can also help you if the midwife asks you not to push (this sounds bizarre, but it does happen if, for instance, you are having the urge to push but your cervix is not fully dilated yet). She’ll probably get you to pretend to have a feather in front of you and ask you to blow the feather with soft little breaths.
A DOULA’S BOX OF TRICKS
Your female friend can bring some of these things to the labour room, too:
An ordinary man’s sock, filled with normal white rice (jasmine rice has a nice smell) with maybe a drop of essential oil such as lavender, tied with string at the top, or sewn tightly, so it won’t open no matter how roughly you treat it. You can put it in the freezer then use it as a lasting cold pack. But more often doulas put it in the microwave for about three minutes and use it for pain relief on your lower back (or indeed anywhere that helps). You want it hot (but not burning). Unlike a hot water bottle it smells soothing, will mold to fit nooks and crannies of your body and is weighty enough for gentle counter pressure.
Tip: After it’s been in the microwave, rest it on your forearm. If it’s too hot there, it will burn the woman in labour, so wait for it to cool a bit.
Hot water bottle/Ice pack
Either can be soothing on her lower back.
Soft drink can/Water bottle
Freeze a regular water bottle or take a soft drink can just out of the fridge. Roll this on the woman’s back to cool her down and relieve pain (also, when the iced bottles melt the woman can drink the cold water).
Comb on pressure points
Get the woman to press a couple of small plastic combs into the palms of her hands for instant (and controllable) pressure-point pain relief.
Lemon
The scent of a lemon helps with nausea. In a hospital, the smell of real lemon or other essential oils (you can put some drops on a flannel and hold it near her face) can also help mask the unfamiliar chemical aromas.
Small fan
A tiny hand-held fan (small enough to not tire out the woman who is holding it) can be good for soothing and cooling in labour.
Spray bottle
Fill this with cold water and use it along with the fan to cool down a woman during a hot summer birth.
Scents: lotions, candles and lights
Candles may be banned from hospitals for obvious reasons, but at home they can be relaxing. Plain massage oil, some drops of essential oil on a flannel or lotion with drops of essential oils in it can do the same thing in a hospital. Massage the woman with these, and keep replenishing the drops of oil on a flannel.
Hand mirror
Some women want to see their baby’s head when it starts to emerge. Often midwives suggest this as a fantastic incentive to push in the final moments.
Mints
Doulas might bring mints to the birth to offer anyone with stinky breath. A whiff of someone’s lunch, or smoke on a midwife’s breath, can seriously turn a labouring woman’s stomach.
A doula will also encourage you not to wear your contact lenses in labour and to take off any body (particularly clitoral/labial) jewellery.
Your ideal labour support person has to be pretty committed to her role. She should be prepared to:
In short, she has to understand that seeing you give birth is a real privilege as well as something that you’ll both treasure forever.
No one organisation fits all doulas just as no one doula fits all women. Finding a doula in Britain today is getting easier. Your best starting point is to make sure you fully understand what you want, and what doulas in general, are for. Currently, in Britain, the best place to find a doula is through Doula UK (DUK) – a non-profit organisation run by women who feel passionately about birth. DUK doulas have private clients but also work in a variety of venues such as prisons, projects for teenage women or refuges. DUK has a map on its website through which you can find a doula free of charge.
There are currently about 150 doula members. About a 30 per cent of these are birth doulas only. Seventeen per cent are postnatal doulas only and the remaining third (that’s over 50 per cent) do both.
Doula UK (DUK) P.O. Box 26678, London N14 4WB. 0871 433 3103 www.doula.org.uk
DONA International This is a US based non-profit organisation run by and for doulas. Right now they are just setting up doula training in the UK. DONA International is the largest organised body of certified birth and postpartum doulas worldwide. In 2002 they had 4,550 doulas worldwide, with 2,432 of those certified. For more information: www.dona.org
Many doulas in training programmes will either not charge or charge very little, and can be extremely dedicated and useful.
OTHER WAYS TO FIND A DOULA | There are other organisations in the UK which claim to be THE way to find a doula. Some charge hefty placement fees and some run training courses for doulas which are frankly inadequate (and even misleading). Avoid any organisation that charges you a placement fee.
If you can’t find a doula in your area do not give up. Some doulas, particularly those in training, will travel from neighbouring counties for you. My doula, Lucy, came from Berkshire (I was giving birth in Oxford).
HOW MUCH DOES A DOULA COST? | A birth doula found via DUK can cost anything from £200 to £500 depending on the area and the doula. Most offer a sliding scale of fees depending on what you can afford. Birth doulas should charge a flat fee (not by the hour). If you can’t afford to pay anything at all, don’t give up. Doulas do sometimes work free of charge (at their own discretion). Some, when they are starting out, will work free of charge just to get the experience (even a less experienced doula can be an asset). DUK also have a small hardship fund (paid to the doula) to cover costs in some circumstances.
A postnatal doula usually charges between £12 and £15 an hour. On average, she works a few times a week (three to four hours) for up to six weeks.
Again, other agencies in the UK may charge fairly large fees for getting you a doula. Avoid these.
CERTIFICATION AND TRAINING | DUK have a code of practice and several accredited trainers. To become recognised by DUK as a doula, you have to have completed one of these trainer’s courses and have attended a minimum of four births.
The Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth by Penny Simkin (Harvard Press, US, 2001)
Mothering the Mother: How a Doula Can Help You Have a Shorter, Easier, and Healthier Birth by Marshall H. Klaus, John H. Kennell and Phyllis H. Klaus (Da Capo, US, 1993)
The New Experience of Childbirth by Sheila Kitzinger (Orion, UK, 2004)
Ina May’s Guide to Childbirth by Ina May Gaskin (Random House, US, 2003)
Doulas: The Future Guardians of Normal Birth? (MIDIRS Midwifery Digest 13:3) 2003 Contact: Midwives Information and Resource Service (MIDIRS), 9 Elmdale Rd, Clifton, Bristol, BS8 1SL 0800 581 009. Or get this online at www.doula.org.uk/books/stockton.pdf (they have great links to other articles on doulas, from the national press and other sources: worth a browse).
DUK: www.doula.org.uk
DONA International www.dona.org
Association of Labour Assistants and Childbirth Educators www.alace.org
The National Childbirth Trust’s information about ‘Birth Partners’ www.nctpregnancyandbabycare.com