Yesterday I raided my local library’s shelf of birth books (not for the first time). It’s times like these that I’m grateful my friends and family recognize that birth is my career interest, and therefore do not panic when they see me schlepping around a cache of baby books. Because September is promising to be my busiest doula month in the birth center yet, the book on the top of my pile was The Doula Book, by Marshall Klaus, MD, John Kennell, MD and Phyllis Klaus, CSW, MFT. I’ve flipped through this book a few times before, but had never really sat down to read every word.
I plowed through The Doula Book in two sittings. While it’s full of noteworthy information, it’s also a strangely angled book. I’m still pondering who the authors expected their audience to be with this book. The subtitle is How a Trained Labor Companion Can Help You Have a Shorter, Easier, and Healthier Birth, somewhat of a contradiction to the main title, which seems to indicate the intended audience are doulas. Only a small fraction of the content seems geared towards expectant parents wondering whether they should employ a doula, some of it is tips for doulas, and the rest is scholarly information on exactly how doulas aid women giving birth.
The most interesting chapter for me personally was Obstetric Benefits of Doula Support. As a doula, I’m constantly having to explain what I do, why the position exists, and why my job is important, especially if a mother has a supportive birth partner. Klaus and Kennell, in addition to authors of The Doula Book, are also Principal Investigators of several studies of birth outcomes in women who have continuous labor support (doulas) versus those who have “traditional” obstetric care, with providers leaving the laboring woman alone for segments of her labor. They combine their data to present their findings here. The results are truly spectacular.
Perhaps the must stunning data comes from investigations of lengths of labor. During my doula training, we learned about what is often referred to as “The Guatemala Study” (Sosa, Kennell, Klaus, et all, 1980). In Guatemala, just as I experienced in India this summer, friends and family are excluded from the labor and delivery room, and women are left without continuous emotional support. In the Guatemala Study, one group was provided with a doula, while the other group was left without continuous labor support. In the no-doula group, the average labor was 19 hours (women came to the hospital early in labor, before the cervix had dilated past 1-2 centimeters). In the women who were given a doula, the average labor was 9 hours. The only difference in care was the presence of a doula throughout the woman’s labor. Had I not experienced similar results first hand this summer, I might have balked at this data. The results though, are so significant that they are glaringly obvious in person. During my own internship in a country where women are left to labor alone, it was obvious that labor sped up as soon as I established a supportive relationship with a mother. It wasn’t unusual for women who had been stalled at five centimeters all day to be pushing within half an hour of my holding their hand and promising to be there for their delivery. After the incredibly rapid delivery of one infant, the nursing staff adjusted their practice to be sure they kept a closer eye on a laboring woman when I or another supportive intern was helping out. While I’m not sure of the particular investigation, a childbirth educator I know told me about another study, I believe also in Central America, in which the investigators were able to show that there was a signficant difference in the length and ease of labor when a woman was simply sitting in the same room as the laboring woman, not even speaking to or interacting with the mother. The most important thing we can do for laboring women is to make sure they know that someone is there for them.
These results have been duplicated in the United States. In 1991, Kennell, Klaus, McGrath, et al, published what is referred to as “The Houston Study.” The study took place in a large, public hospital in which medical residents cared for mothers with a uniform care philosophy, with guidelines as to bed confinement, fetal monitoring, artificial rupturing of membranes, Pitocin use, etc. First-time mothers were either provided with a doula or not. In the study of 416 women, the 204 women who were not provided with a doula had labors averaging 9.4 hours. The 212 women who were given continuous labor support by a doula had an average labor of 7.4 hours. This is a statistically highly significant difference. (The shorter overall length of labor compared to the Guatemala Study can be attributed to differences in care, such as the use of Pitocin to speed labor, and when women were admitted to the hospital: four centimeters compared to one or two.)
Beyond the length of labor, there were other remarkable differences in how women fared with or without a doula. Of the 204 women who delivered without the support of a doula, 25, or 12%, delivered naturally (in this study “naturally” means a vaginal delivery without the use of anesthesia, artificial oxytocin or other medications, or forceps). Of the 212 woman who received continuous labor support, an astounding 116, or 55%, delivered their babies naturally, a statistically highly significant difference. The use rate of artificial oxytocin (Pitocin) in mothers with no doula was 44%, compared to a rate of only 17% for women who had a doula, a statistically highly significant number. The cesarean rate in mothers without a doula was 18%, while women who had a doula needed cesareans only 8% of the time, a statistically significant difference. It is amazing that the only difference in care between these two groups is the presence of a supportive stranger. Frankly I’m surprised that this study (and the dozens like it) haven’t completely changed the face of obstetrics over the last twenty years. The true medical (and financial) outcomes far outweigh the difficulty of setting up doula programs.
The benefits of having a doula even went beyond the mother and to the baby. In infants whose mothers had a doula, only 10% were kept in the hospital for longer than two days. In infants whose mothers did not have a doula, 24% stayed for more than two days, a statistically significant difference. When the investigators examined why the differences may have been present, they found one main reason for the disparity between the infant groups: maternal fever. Maternal fever developed in 10% of women with no doula, but only 1% of women who had a doula again a statistically significant difference. Interestingly, a British study (Fusi, Moresh, Steer, et al, 1989) showed that when a woman receives epidural anesthesia her body temperature surely but steadily rises, and if her labor is long enough (and births with epidurals are often longer) her temperature will eventually become a bona-fide fever. And how do we lower the epidural rate? Use a doula!
There are also many long-term results of a doula-supported birth. Multiple studies have indicated better results in breastfeeding, less postpartum pain, less postpartum depression, fewer infant health issues, better mother-infant bonding, higher self-esteem in the mother, and higher rates of mothers reporting their babies as less fussy, more clever, more beautiful and easier to manage than an average baby.
Everybody wins with a doula. The mother has a shorter, easier birth and comes away with more confidence and fewer complications. The baby is less likely to have complications, and has the added bonus of a more relaxed, attentive mom. The father or birth partner is relieved of some anxiety, and able to provide more loving, personalized support to his partner and child (more to come on that). Studies have even shown that the relationship between the parents often improves when a doula was present at their child’s birth, but remains the same when they labored alone (Wolman). Nurses are relieved of emotional support duties, and are able to better focus on the medical aspects of birth that they were trained for. Doctors and midwives are more likely to be dealing with simple, natural births that are faster and require less monitoring. Financially, even with the cost of doula services, reducing the cesarean and epidural rates in hospitals would save billions of dollars a year, and save individual families about a thousand dollars per birth. Best of all, there are community doula programs, like the one I work through, that offer doula services for free! How could you say no to that?