A doula (//), also known as a birth companion, birth coach or post-birth supporter, is a non-medical person who stays with and assists a woman before, during, or after childbirth, to provide emotional support and physical help if needed. They also may provide support to the mother's partner and family. Unlike a midwife, doulas are not classified as medical professionals and therefore cannot administer medication. Doulas are typically certified with some courses taking over a year to complete. Practical training is involved to become certified. Continuous support during birth from a person outside the mother's family or social circle, such as a Doula, is associated with reduced mortality rates, improved overall health of the mother and the baby, shorter labor time, reduced risk of a C-Section, and a lower need for medical interventions such as instrumental delivery or pain relief. Support from a Doula may also reduce mothers' negative feelings about their childbirth experience. Some doulas provide postpartum support, for example assisting with housework, cooking, and offering help with learning to breast feed.
Major doula organizations that offer certification programs include Doula UK, DONA International, Childbirth International (CBI), Birth Arts International, International Doula Institute, Birthing From Within, CAPPA and the Australian Doula College. The Australian Doula College also trains end-of-life doulas.
There is a movement to encourage certification, and provide documentation of it on consumer websites such as Doulas and DoulaMatch where mothers can find certified doulas, childbirth educators, yoga instructors, and other birth-related professionals. Doulas not trained by a formal organization can be controversial within medical settings due to a lack of formal medical education when a discussion regarding medical interventions in labor versus pursuing natural childbirth without an epidural or caesarean section arises; however, the role of the doula is not to offer medical advice.
History and etymology
The term doula was first used in a 1969 anthropological study conducted by Dana Raphael, a protégée of Margaret Mead, with whom she cofounded the Human Lactation Center in Westport, Conn. in the 1970s. Raphael suggested it was a widespread practice that a female of the same species be part of childbirth, and in human societies this was traditionally a role occupied by a family member or friend whose presence contributed to successful long-term breastfeeding. Raphael derived the term from modern Greek (δούλα, doúla, "servant-woman"), as told to her by an elderly Greek woman, Raphael also describing it as coming from "Aristotle's time", an Ancient Greek word δούλη meaning "female slave". Marshall Klaus and John Kennell, who conducted clinical trials on the medical outcomes of doula-attended births, adopted the term to refer to a person providing labor support.
Types of support
The overall goal of a doula is for the mother to feel safe, be informed and feel comfortable, enhancing the role of doctors and nurses which is to ensure a safe delivery for mother and child. Doulas have no clinical role, duties or decision-making.
A birth doula is also called a labor doula. The kinds of support provided during childbirth may include physical assistance and comfort (massage, maintaining a supporting posture or providing water), emotional support (providing company, encouragement or simply talking in a soothing tone of voice), and acting as an advocate for the woman undergoing childbirth (suggesting options or supporting the woman's decisions to a medical team). Doulas may also be involved during pregnancy and after birth (postnatal care).
Most doula-client relationships begin a few months before the baby is due. Before the labor, the doula and the family can develop a relationship where the mother and her partner feel free to ask questions and express fears and concerns, and where the mother can take an active role in creating a birth plan. Continuity of support by the same person is thought to be an important aspect of the relationship between doula and mother. Doulas may be found in hospital, community-based programs as well as private practice, doula agencies and may be reimbursed by insurance companies or out-of-pocket by clients. Because insurance companies typically do not cover the cost of hiring a doula, they are more popular among middle- and upper-class parents.
Postpartum doulas provide educational support and practical support in the home in the first weeks and months after childbirth or after adding an infant to the family. The same doula often provides both birth and postpartum services. They provide emotional support and companionship by encouraging a mother when she might be feeling overwhelmed. Other workers providing similar services are maternity nurses, newborn care specialists, and, historically, monthly nurses.
An antepartum doula provides help and support to a mother who has been put on bed rest or is experiencing a high risk-pregnancy. Emotional, physical and practical support can be provided by an antepartum doula in these circumstances.
Continuous support during labor provided by doulas (along with variety of groups such as nurses, midwives, other hospital staff, partners, family or friends) have been associated with improved outcomes for both mothers and children.There is research to support the beneficial effects of doulas on both maternal and newborn or infant health, including shorter delivery, fewer caesarean sections and complications, the use of fewer medications and fetal extraction tools, less time in neonatal intensive care units, positive psychological benefits for mothers, more satisfying birth experiences, and increased breastfeeding. Cross-country research on the effects of doulas on child birth and postnatal care is complicated by the variety of settings, cultures and medical systems of individual countries and characteristics of patients. These benefits appear to be contingent on the doula's providing continuous rather than intermittent assistance, have some medical training and on the specific social and cultural setting within which their services are provided. Women with less education, lower incomes, less preparation for childbirth and those lacking social support may experience greater benefits from doula care than other groups.
Until recently, the American College of Obstetricians and Gynecologists has no official position on trained labor support (of which a doula is considered to be), during an interview the ACOG's chairwoman of the academy’s committee on obstetric practice Sarah Kilpatrick, stated while doulas may be helpful, there are some who try to "interfere with the medical aspect of delivery." In March 2014, the ACOG put out a Consensus Statement titled "Safe Prevention of Primary Cesarean Delivery" in which it said, "Increasing women’s access to non-medical interventions during labor, such as continuous labor support, also has been shown to reduce cesarean birth rates." As more research has become available on the positive benefits of trained labor support provided by someone not employed by the hospital, in 2017, ACOG officially announced the need for all women to have access to continuous labor support outside hospital staff. While they do not mention the word doula in this committee opinion, doulas definitely fit within this definition. The official committee opinion put out by ACOG also offers other recommendations that will allow women more choice and access to more supportive care. Doulas could be utilized to help achieve many of these recommendations as they move towards better collaboration.
Doulas provide information about medications or medical interventions during childbirth and help the family decide if her practice fits the family's birth wishes such as those who decide to have an epidural or otherwise do not undertake natural childbirth. Doulas acting beyond the role of social support and advocacy by providing medical advice, practicing outside their scope of practice may be acting as a traditional birth attendant.
In 2017 the United Kingdom's Royal College of Midwives published a position statement on doulas.
Training and certification
There is a lack of standardization and oversight of doulas, with multiple organizations providing different courses with varying requirements. There is no formal or universally recognized certification process or training requirements, and anyone can refer to themselves as a doula. No academic credentials such as a college or university diploma, or high school equivalency are required. . Doulamatch.net, an online referral page for doulas, has offered a list of items that students should look for as they begin looking for training. Amy Gilliland, a researcher on doula care and culture, also lists some qualities a training program should have. Some theorists have stated that it may take college level work or more in depth online eduction in order to provide some of the communication skills that may be necessary.
Being a doula does not specifically require any medical training, although it is not uncommon for doulas to have received certification or medical training of some kind. In North America, training generally takes the form of a two- to three-day seminar, and some experience with childbirth. Trainees may have hands-on practice with various techniques used during childbirth, including maternal positions and movements, relaxation and breathing exercises and other measures that could be used for comfort. Certification can occur through organizations at various levels (local, national or international) and some require positive evaluations from medical professionals. Certification may also require, in addition to attending a training course, time spent working or learning about maternity care and childbirth classes and possibly a written exam. Some doulas train through distance education. Research also supports the effectiveness of female friends or relatives, after minimal training, as a low-cost alternative to professional doulas.
Disputes between doctors, nurses and doulas have been described as a "turf battle", though it is also recognized that doulas and nurses can occupy complementary roles that provide opportunities for mutual learning and assistance. Some hospitals have created internal doula training programs to reduce conflict between doulas and medical staff.
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