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What Do Doulas Do?

We are often asked, "What do you do?"

The best way to answer that question is to look at the usual situation: labor without continuous support. Few life experiences are as fraught with negative stereotypes as the process of giving birth. The image of the screaming woman with out-of-control pain is the specter we encounter when we start down the path of having a baby. Contemporary life, if anything, has worsened the situation. At an earlier time, a woman would have been surrounded by family and friends. Now, family may be hundreds of miles away. Even if they are nearby, they may not be helpful, if they have absorbed these cultural messages, as well.

The continuous presence of a sympathetic, knowledgeable companion can do much to restore the concept of birth as a manageable, normal human experience. The jury is in: our presence is linked to fewer cesarean births, reduced need for pain medication, fewer inductions, and a more positive view of the birth experience.

However, if we just list these outcomes, we would think that a doula simply helps people dial up better births, the way people order flannel-lined jeans online from LL Bean. This would be a flawed view for several reasons. First, we cannot offer guarantees. An unplanned cesarean can still happen; a baby can still require NICU care. When we put such expectations on the doula, we create a consumer mentality. We treat birth outcomes like a purchasable commodity.

It is more accurate, instead, to view the doula as putting something back into birth that contemporary life has devalued: the support of a sympathetic woman. Support may start at the mother’s home in early labor, or a hospital-based doula may meet the couple for the first time at the hospital.

In either scenario, one key advantage is that we are not afraid. Therefore, our presence dissipates any fear that the mother and partner may be feeling. When fear goes down, so does the tension that feeds pain.

The doula provides continual, compassionate presence; her knowledge about the birth process; and her familiarity with comfort measures. She customizes all this to the individual woman. The doula may do something as simple as assure the mother and partner that bloody show is normal. She may notice the mother frowning during contractions and put a finger on the woman’s forehead to help her know where to release tension. If back labor is present, she may apply double-hip squeezes and guide the mother through pelvic tucks and rotations to relieve the pressure.

Perhaps the doula’s greatest contribution is her knowledge of what her scope of practice entails and what is beyond that scope. Cervical checks, blood pressure assessments, diagnosis of illness – are all beyond our scope of practice. If we stay with what we do best, we focus on the support we offer as doulas; if we move beyond that scope, we devalue the work of labor support. This boundary helps us concentrate on the mother’s physical and emotional comfort without overlapping or contradicting the staff.

We work with the partner as well as the mother. We don’t scoot the partner off to the side; we collaborate. Our calming presence frees the partner to participate more fully. We also find some way to compliment or praise the partner so that he or she can perceive the value of his or her participation.

Another critical limitation is that, while we support the mother, we do not speak for her. We are the best representatives of our profession when we listen to the mother, give her information, and support her speaking for herself. Therefore, we respect her adulthood and her parenthood. (If a provider recommends something that deviates from her requests, we may discuss this privately with the mother. However, we let her decide whether to bring the matter up.)

Doing what we do best highlights our true areas of excellence. Among the host of comfort techniques that we know, we can offer and apply the ones most appropriate to the specific situation. Our reassurance and our knowledge help convey that labor is a manageable process, part of the normal human experience.

We may best see the role of the doula if we use the metaphor of the theater. The plot is the birth process; the star is the mother-baby unit; the second major character is the partner. Next are the staff. The doula’s role may seem small. She is the quiet supporter – primarily of the mother, but also of the partner. However, a partner often says afterward that the doula’s reassurance helped him or her to feel less stress and to support the mother more effectively than he or she would have alone. We also view ourselves as collaborating with the staff. A doula may occasionally overhear a nurse, midwife, or obstetrician refer to her as “amazing.” While amazement is a nice bonus, it happens rarely. More often, we know we are helping the staff if they smile and then proceed to ignore us.

If we simply reduce fear, increase comfort, and help our clients and their partners travel the journey of birth with confidence, we accomplish much. We fulfill our noble purpose and enact our invaluable role.

(Another version of this blog is being submitted as the essay required for certification by Doulas of North America [www.dona.org ]).

Paula Moyer