The most important thing that a doula can do is the personal touch. A woman carries her birth experience through her whole life. It shapes her. To find out more about how a doula supports women and families during the childbearing year, please visit www.motherwit.ca or e-mail firstname.lastname@example.org.
“If a doula were a drug, it would be unethical not to use it.”
–Dr. John H. Kennell
Midwifery was reintroduced as a regulated profession in most of Canada’s ten provinces in the 1990s.
Interview with a Doula in 2013 by Susan Dubrofsky
Q. What is a doula?
A. A doula, usually a woman, provides informational, physical and emotional support to a woman and her partner in the childbearing year, which includes the prenatal time, labour itself and the postpartum period. This profession is old as time. Women have always given birth in the presence of other women. It’s a quirk in our evolutionary process that we now give birth in hospitals often with a lot of men present, and even, following the newer fashion, with fathers present in the delivery room.
Q. What is the difference between a midwife and a doula?
A. A doula does not provide clinical care. A midwife is trained in emergency resuscitation techniques and does vaginal exams, blood pressure checks and other things. A doula is emotionally, not medically, responsible for the mother’s care. We provide physical support like massage techniques and suggestions for positional changes during labour. Many people who hire us would have liked a midwife but couldn’t get one. In Quebec, only 1 out of 4 women who want a midwife get one, because we don’t have enough midwives. A woman who wants a natural birth finds herself with an obstetrician in a hospital and because she wants someone who is more holistic in her approach to support her, she has a doula. Then she has the best of both worlds.
Q. Why are there so few midwives here?
A. Midwifery became legal in Quebec in 1999. It takes four years for a midwife to certify, in Trois-Rivières, and then the midwives take maternity leave to have their own babies which causes this dearth of midwives. There are three midwifery centers in Montreal and you are on a waiting list when you call.
Q. Why did you become a doula?
A. I became a doula after I had my son. I did what everybody does when you get pregnant, I went to an obstetrician and had my five minute appointment every month. Then we moved from Vancouver to Edmonton and I needed a new care provider. I was reading Guide to Childbirth by Ina May Gaskin and what she wrote made sense to me, how birth works best when we are undisturbed and when our hormones are allowed to do what they need to do and how being interrupted, bright lights, lots of questions, can disrupt the process and slow things down. At the back of her book, there is a list of questions to ask your caregiver. I made an appointment with an obstetrician guy in Edmonton. I go in, sit on the examination table. He comes in. He doesn’t look me in the eye. He doesn’t even look at ME. He does the examination. He’s about to leave, and I say, I have questions, and he takes an exasperated breath: “Yes?” My first question was, “What is your c-section rate? He looks me in the eye then and says, if you need one, you’ll get one.” And he left. I was put off by this and I wanted a midwife instead, but because it was illegal in Alberta at that time in 2003, where could I get one?
My mother-in-law, a research nurse, informed me of a government pilot project to see if midwifery could work in Alberta. A half hour away there was this small group of midwives who were covered under Medicare and I went to see them. It was like night and day. They were interested in me and in my baby.
I understand that women giving birth, at the hospitals and elsewhere, is something that happens all the time and it’s hard to maintain, as a professional, your awe of the process, but this group was interested in me. The appointments lasted an hour instead of five minutes. They examined the position of my baby and asked if I wanted to hear the heartbeat. When I went into labour, I delivered in a birthing pool in a birthing centre attached to a hospital. It was quiet, the lights were dim. I pushed my baby out and that was awesome and I thought, I want to be a midwife.
I don’t just support natural birth, I support a woman’s right to be empowered and to make informed decisions every step along the way. At the end, no matter what happens, she feels she was an active participant in her own experience and she wasn’t just passive and going, well, they told me to do this, and well the doctor said this, so that’s what I did.
Ultimately, I chose to become a doula instead of a midwife, because I saw a need for women to have continual support in birth, whether in hospital or in a birthing centre. I would rather hold emotional space for my clients than to be clinically responsible for them.
Q. Why would women chose using a doula over or with a hospital environment?
A. I have great respect for people who work in hospitals, the nurses, doctors, obstetricians. I have seen them save lives and seen them cry with a woman who had a disappointing experience, but I have also seen the protocols followed in the hospital. It’s a stark environment. It doesn’t leave a lot of room for what a woman needs. When a woman delivers, whether she’s looking for a natural childbirth or she’s looking to go as far as she can before she gets an epidural, she needs to feel safe.
She needs to feel that everyone around her trusts what she is doing. There is a natural hormonal process. A hormone called oxytocin is responsible for contractions. It is also the hormone responsible for falling in love and for bonding. It has two different purposes but they come together importantly at this time. Oxytocin levels are negatively impacted by adrenalin, which is the fear hormone. One story– a friend of mine was pushing her baby out quite nicely, the head was showing up, and some nurse popped her head in and said: “Look at the size of that head, how are you going to push that out?” And the baby withdrew. The mother’s body sucked her baby right back in. She had another two hours of labour after that disruption. We are primal in labour. We are vulnerable to intrusions. If there is something that tells your body it’s not safe to have your baby right now, your baby is not going to come. It’s as simple as that..
Q. Has there been a change in birthing techniques in hospitals in the past 50 years? And are they better?
A. From the 1930’s to the 1950’s, and in some places, in the 60’s and 70’s, when a woman went into labour, she would strapped down to a bed and given a drug, Twilight Sleep (scopolamine), that knocked her out so she was unaware, but still behaving. She would respond to commands but she wouldn’t remember any of this later. She would be tied down until she was fully dilated and then given an episiotomy and then they would get the forceps and extract the baby from her. She was delivered of her baby, a passive participant in what should be an active process. This was in the hospital. Some women gave birth with family doctors in the country and that was different. Forty years ago when I was born, my mom was drugged from the moment she got in. They gave her a spinal, like an epidural, which numbed her. Eventually she received an episiotomy and there were forceps involved. She was 20 years old, and having read a book about breast feeding, she said, “I would like to breast feed my baby,” and the doctor said, “no,” because formula with carnation milk, was “scientifically proven” to be the healthiest for babies. At that time they would take the baby and put it in a nursery. She asked for me and they brought me to her and she said to the nurse, “I would like to breast feed her” and the nurse said, “there’s no point, the doctor gave you the medication to dry up your breast milk just after you delivered your baby. “ Years later, when I had my baby in the water, my mother was present. Quietly from a corner, she watched me deliver, watched me breast feed and then said, “He shouldn’t have given me that medication.” Now I think that was an assault. I know this is a strong word, but giving someone medication without their consent, without telling them what it does, is assault, even though I know that that was the protocol then. And so we have generations where breast feeding was lost.
Thirty years, fathers were allowed into the delivery room. We saw a movement towards Lamaze and the Bradley method which use breathing techniques to cope with labour which gave some control back to the mother. There are exercises you can do with your partner and both go into the delivery room to have their baby. Women had less medicated births, because these techniques gave them better control over their experience.
Breast feeding gained in popularity. Ten, fifteen years ago, you had your baby and the baby was brought to the nursery. Now, you have your baby and the baby stays with you all the time. You are never separated from your baby, unless there is a medical issue. Baby is immediately skin to skin, right on your chest and even rooms with you in the postpartum ward.
Not so good is that the birthing scenario we often see is very managed…somewhat less so in Canada than in the United States. What I mean by managed is that if you don’t have your baby by ten days past your due date, in North America, they like to induce you. That means they give you drugs to begin your labour process. There is a study that shows there is a slight decrease in still births when you do. The problem with that, is that studies suggest that instead of inducing everybody ten days after their due date, we should monitor them, make sure the baby is doing well and then induce only if the baby is not doing well. But we skipped past the monitoring, because of lack of funds or time or energy, so we just automatically induce. With the midwives in Quebec, we wait two weeks, in Europe, they wait two to three weeks and there is a better outcome in terms of neonatal mortality. A lot of women face the induction scenario, because the average first-time moms deliver their babies eight days after their due date.
Here we have lost patience. We are rushed. Doctors don’t have the time to wait the ten or more days. They have twelve people, or more, in the waiting room, to see. It’s easier to schedule an induction rather than wait two to three weeks. They mean well but an induction is a difficult process for a woman to go through. It’s a more painful version of labour, and then there are the drugs that they give. The main drug they give is Syntocinon, Pitocin in the States, a synthetic Oxytocin. It was not manufactured to induce labour. When we induce a labour in a woman who is not ready to have her baby, it can take longer. We have a long process ahead of us, which is the least of the problems. It is more painful. This drug is not the same as our own oxytocin. Our oxytocin interacts with endorphins, so that as your oxytocin trundles along giving you contractions, it goes into a feedback loop and releases endorphins as the same time, to buffer the pain. So in the middle of labour, the mother will be almost “high,” eyes rolling back in her head and rocking between contractions, because her endorphin levels are through the roof. The synthetic oxytocin that they give, does not cross the blood brain barrier, so it does not interact with the endorphins. Instead of having wave-like contractions, you are slammed by them. So the epidural rates are enormous in induced labour because that level of pain is something we are not designed to deal with. A risk of induction drugs, is that they can cause hyper stimulation of the uterus, and the baby doesn’t like that and now we have to have a c-section. My job, as a doula, is to help a mother go as long as she can before she needs an epidural, with massage, keeping things calm and explaining things so the woman feels like she is coping and managing things. With the drugs they give, we go from coping and managing to suffering like a snap of fingers. We get the epidural much earlier. I might see a mom getting an epidural at 6, 7, 8 centimeters when she is having an un-induced labour and she will get it at 2 or 3 with an induced labour. If you get an epidural late, you are in good shape, but if you get an epidural early you have a much higher chance of having a c-section because birth is physiological. It is based on hormones. It is based on gravity. A woman who is in labour—she will be walking through the house, she’d be standing and rotating her hips, she’d be kneeling on all fours, she’d be doing anything but lying down. If you’d ask a woman in labour to lie down, even for a vaginal exam, she would resist, it’s uncomfortable, I don’t like it, I don’t want to lie down. Lying down is not your body’s response to labour. Your baby is coming down, impinging and pressing on nerves, with gravity helping that process. An epidural cuts off all our pain sensations and there is a reason we have pain in labour. That pain tells our body what position we should take to facilitate the baby’s progress. I don’t have an ultrasound, I don’t know where the baby is at any given time during my labour, but I know that my back hurts and that says the baby is saying, I’m pressing in this area now and I need to make space, and I know my back won’t hurt as much if I go on all fours. If I do, baby has room and baby can move down. The pain signals are telling us what we need to do.
In hospitals, I encourage positioning as much as possible. We are not confined to bed anymore, another positive change. You can walk around as much as you want – unless you have the epidural.
Q. What do you do as a doula?
A. I see the mother and her partner, three times before the baby is born, then at the birth, and again after the baby is born. The prenatal visits at their home lasts about two hours. Health history, past pregnancy, diet, nutrition, exercise, what kind of birth is desired – these are all discussed. When should they go to the hospital? And if it is a home birth, we talk about when to get the midwife there. Maybe they don’t want a natural birth, but I need to know. I am there to support what they want. I want them to be informed every step of the way so they can make the better decision.
Doulas are becoming popular. At MotherWit, we have “Meet The Doula” night every second Wednesday of every month. It’s packed. Doulas bring calm and a sense of normalcy to the birthing room, so that the labouring mom and her partner feel unafraid and secure.
Q. How does the hospital staff treat a woman in labour when a doula is present?
A. I have gotten to know the doctors, nurses and other staff at the hospitals I have been in and the vast majority of time, they are happy to see a doula because they know the mother has someone with her continuously. As far as the demands of nursing and doctoring are concerned, they don’t have time to spend with their patient. Nurses would love to spend an hour rubbing a patient’s back. They can’t. They have four or more other patients they are responsible for and charts to fill out. The nurses show where things are and they leave and now two people, alone in the room who have never done this before, say, okay, I guess we’re going to have a baby. Part of my role is to be person who has experience. When mom is squatting in a corner and roaring, dad can look at me: “Is this normal?” And I respond, it’s beautiful, she’s doing a wonderful job. The room is calm and cool. I have aromatherapy going, the lights are dim and the doctor comes in, it’s so nice in here.
Q. What changes would you make to hospital birthing techniques?
A. Doulas would be covered under Medicare. We are as effective, more effective, than an epidural. Dr. John Kennel said, If a doula were a drug, it would unethical not to use it. I would incorporate midwifery into the hospital system. Midwives have this focus on the person, the holistic state of the mother, rather than the vagina, the cervix and the baby which is sometimes what doctors find themselves focusing on. I would couple midwifery care with obstetrics. A nurse told me that in a couple of years they will have this at St. Mary’s Hospital here in Montreal.
In hospitals, we have fallen into this conveyor belt of care. You come in, you get the IV, although you can decline the IV unless medically necessary. You get the IV and you go on until you get the epidural, which is pretty soon because you have no one there to support you, no nurse, no doula, just your partner who can be overwhelmed, and you have the epidural early, which means you’re going to be lying on your back or side with the baby saying, I really need you to be on your hands and knees right now to get down and now I can’t get down and it’s going to take a really long time. Now we give you drugs to up your contraction rate, so your contractions are coming faster and baby is saying, I don’t like this and it hurts, so maybe you need a c-section. If it’s a vaginal birth, we might need instruments to help baby out, like the vacuum or the forceps—instrumental delivery is twice as likely when mom has an epidural. If you have forceps, you’re going to have an episiotomy on top of that, which can be very painful postpartum. The baby is delivered with forceps, sore in his neck and shoulder, who now when he breast feeds, doesn’t like turning his head this way in the first little while because it hurts, and so one breast becomes more engorged than the other, and so breast feeding is hard and painful and mom and dad are tired and discouraged and now they are using formula.
This is called the cascade of intervention which is a variety of interventions that cause a chain of possible effects or outcomes. With doulas or midwives working along doctors, this cascade could be avoided.
Q. I found these following statistics when a midwife or doula is used in birthing:
50% fewer caesarean sections
Reduction in the use of forceps vacuum by 40%
60% fewer requests for epidurals
40% reduction in the use of synthetic oxytocin for inductions or augmentations
30% reduction in use of pain medication
25% reduction in labour length
Increased rates of breastfeeding at 6 weeks post-partum (51% vs 29%)
Higher self-esteem (74% vs 59%), less anxiety (28% vs 40%) and less depression (10% vs 23%) at 6 weeks post-partum
How true are these statistics?
A. This is from a study from Klaus, Kennell, and Klaus (1993). A more recent Cochrane review from 2012 further supports the idea that doulas make a huge difference in birth. We talk to the mother every step of the way. If there needs to be a c-section, they’re not just whisked away (unless there is a true emergency), they are prepared for it. We talked about episiotomy that was protocol, everyone had one, twenty, twenty-five years ago. At that time, a study came out that it’s better not to give an episiotomy. It took years after the study came out, to change that protocol. They were giving episiotomies because everyone was having forceps birth. They stopped using forceps all the time, but were still giving episiotomies. Today we are not having episiotomies any more unless medically indicated.
Q. What changes would you make to hospital birthing techniques?
A. I see a great reliance on numbers. How dilated is this woman? How many minutes apart are her contractions? It is a generalized belief that we can look at these numbers and tell how far along she is. This is somewhat true but every woman’s body is different. I look at a woman’s behaviour. A woman comes in and they do an exam and she needs to get 10 centimeters dilated to start pushing. She’s coming in at 4 centimeters but she’s roaring through her contractions and she’s behaving in a more advanced fashion. I know she’s going quickly. But the staff will often go, you’re going to need more hours, you’re only 4. There is a progression chart, but not every woman follows it. I can tell a woman’s behaviour doesn’t necessarily match the figures. The most important thing that a doula can do is the personal touch. A woman carries her birth experience through her whole life. It shapes her. As advanced as we are medically, with our university degrees, fancy jobs, things that we have, at heart, when a woman is pregnant, it is personal. It is what her body was meant to do. If she is attached to machines and given drugs and has surgical procedures, she comes out thinking, my body doesn’t work. Ina May Gaskin said, Your body is not a lemon.
Q. Any last thoughts?
A. I would like to see doulas available to every woman who wants one. I would like to see doctors (I know some who do) talking about doulas to their patients. Every obstetrician should come with a doula to follow the birth from start to finish. Doctors don’t see the whole process. They see the end when the woman has her feet in the stirrups, legs spread and they catch the baby and say, congratulations, lovely baby. They weren’t there at 3 am when she was throwing up, or there when she decided that she wanted to be naked and tore off her clothes and howled at the moon. I watch this woman in her power as she has her baby, as she brings her baby into the world. It’s why I do this work. I witness the true essence of woman, of family, every time I attend a birth.
Terminology from Wikipedia:
An episiotomy also known as perineotomy, is a surgically planned incision on the perineum and the posterior vaginal wall during second stage of labor. The incision, is performed under local anesthetic and is sutured closed after delivery.
Epidural techniques frequently involve injection of drugs through a catheter placed into the epidural space. The injection can result in a loss of sensation—including the sensation of pain—by blocking the transmission of signals through nerves in or near the spinal cord.
A Caesarean section, also C-section, is a surgical procedure in which one or more incisions are made through a mother’s abdomen and uterus to deliver one or more babies.