I have received alot of lengthy responses to my blog of December 12 Doulas: Newest Accessory in Lucrative Birth Biz. First, here is the response from DONA International:
Official Response to Article in BMJ – Dr. Chakladar
In response to the recent article about doulas (BMJ 2009;339:b5112, doi: 10.1136/bmj.b5112, Published 1 December 2009) by Dr. Abhijoy Chakladar
Dr. Abhijoy Chakladar recently wrote an article about doula support in the British Medical Journal (Dec 1, 09). There he questions the role and training of doulas, suggesting that midwives should be performing these duties, and that doulas may compromise care by disrupting the relationship between the medical team and mother.
As the premier doula organization, representing over 7,000 doulas, DONA International takes the opportunity to offer a rebuttal to this article.
The importance of fostering relationships between parents and infants cannot be overemphasized, since these early relationships largely determine the future of each family and of society as a whole. The quality of emotional care received by the mother during labor, birth, and immediately afterwards is one vital factor that can strengthen or weaken the emotional ties between mother and child.
DONA International is the largest certifying organization for doulas in the world. While the doula field is not currently regulated, parents and providers can find reassurance in the scope of practice that all DONA doulas agree to - and are governed by - in becoming certified through, or members of, the organization. This scope is defined as such:
Doulas specialize in non-medical skills and do not perform clinical tasks, such as vaginal exams or fetal heart rate monitoring. Doulas do not diagnose medical conditions, offer second opinions, or give medical advice. Most importantly, doulas do not make decisions for their clients; they do not project their own values and goals onto the laboring woman.
DONA International believes that doulas are an integral part of the maternity care team supporting their clients emotionally and physically. Doulas provide access to evidence-based information so their clients can make the decisions that are right for them. Doulas fill a gap and a need that currently exists in virtually every health care system around the world. As Louise Silverton, Deputy General Secretary of the Royal College of Midwives, claims in the article, “midwives simply do not have the time to provide the kind of emotional support that doulas are offering.”
Dr. Chakladar questioned whether “the doula business is actually necessary or whether it is exploiting – for profit – unspoken fears about NHS perinatal care and the seemingly limitless market for birth related products and service”. We can report with confidence that doulas are not drawn to the profession by the earning potential. On the other hand, healthcare systems, governments and the public incur an enormous burden of expense for the many interventions inherent to an otherwise normal labor, birth and immediate postpartum experience for mothers and babies due to frequently unnecessary and excessive procedures and interventions considered routine. Multiple grassroots, consumer and governmental organizations are working diligently to enlighten childbearing families and maternity care providers of the importance of evidence-based practice and informed decision-making. DONA International is but one of those organizations and it is for this reason that some birthing families desire the support of a knowledgeable and experienced doula.
Dr. Chakladar questions the motivation to hire a doula by the parents referred to in the article; "Both the mother and father were confident and articulate, so I couldn't help but wonder why they needed to pay for support." The assumption in this statement is that confident and articulate people cannot benefit from the support and guidance of a compassionate professional advocate.
A doula is the cultural surrogate for the extended family that used to surround and support women in their childbearing year. Modern culture dictates that most women will give birth never having witnessed the birth of another woman nor will she be supported by women who have the knowledge and skills that their female relatives used to bring to the situation. Doulas “mother the mother,” providing continuous support and filling the void in today's under-resourced medical systems.
The hormones of labour cause a natural shift in awareness, which can greatly impede a woman’s logical and objective judgment. Partners may be insecure in their ability to fully comprehend the risks and benefits of common procedures or to effectively seek out this information during labour because of their strong emotional involvement in the process. When parents express confusion or have questions beyond what their care provider has offered, the doula helps them access additional information and validate its basis in evidence to aid in their decision making. A doula works for her client, understands her client’s motivations and goals and can therefore provide objective responses tailored to her client’s individual needs. She builds a relationship of trust and confidence with her client, something most healthcare providers simply do not have the luxury of doing.
Perhaps Dr. Chakladar’s statement, “that the kind of women who are very determined to achieve a ‘normal’ birth are more likely to hire a doula than those who do not see medicalised childbirth as a problem” contains an element of truth. The real questions are two-fold – what defines normal birth and why would not all women deserve a normal birth? An abundance of research has been carried out regarding the benefits of doula support during labor and birth and the results consistently show better maternal outcomes, reduced intervention rates, greater satisfaction and better neonatal outcomes, regardless of women’s choice for pain relief. Penny Simkin, one of the founders of DONA International, states, “Doulas can only control how we care for our clients.” The individual doula’s focus is not about statistics or changing outcomes as much as it is about meeting the emotional needs of her laboring client and knowing what emotional suffering looks like so that it can be avoided.
When maternity care providers and doulas work in concert to meet the needs of the labouring mother, the best outcomes are achieved vicariously. Doulas have the advantage of becoming intimately involved with their clients, understanding their fears, desires and goals, this involvement does not encroach on the role of the medical care provider. Instead, the doula’s role fills the cultural gap that continues to grow as our worlds expand and our family structures change.
Dr. Chakladar, doulas do not want women to “feel failures if they have an epidural, or they end up having an instrumental or Caesarean birth.” DONA International and our member doulas do believe, however, that it is every woman’s right to be informed of the risks of all such interventions, both short- and long-term, that they be given the options and the support necessary to become full partners in their healthcare decisions, and that they be honored and respected physically, spiritually and emotionally in order to come away from the experience more confident and complete.
About DONA International
DONA International is the oldest and largest doula association in the world with approximately 2,800 certified birth and postpartum doulas and over 7,000 members. This international, non-profit organization supports doulas by providing quality training and meaningful certification.
For further information, please contact:
Stefanie Antunes, Director of Public Relations
p. (888) 788-DONA (3662) PublicRelations@ DONA.org
1- Doula Position Paper, which includes (but not limited to) Hofmeyr J, Nikodem VC, Wolman WL, Chalmers BE, Kramer T 1991& 93; Langer A, Campero L, Garcia C, Reynoso S. 1998; Martin S, Landry S, Steelman L, Kennell JH, McGrath S. 1998; Landry SH, McGrath SK, Kennell JH, Martin S, Steelman 1998.
2- Childbirth Connection, www.childbirthconnection.org; Coalition for Improving Maternity Services (CIMS), www.motherfriendly.org/; Lamaze International (www.lamaze.org); ICEA (www.icea.org)
British Columbia Perinatal Health Program
3- Doulas: Making a Difference, video.
 Doula Position Paper, which includes (but not limited to) Hofmeyr J, Nikodem VC, Wolman WL, Chalmers BE, Kramer T 1991& 93; Langer A, Campero L, Garcia C, Reynoso S. 1998; Martin S, Landry S, Steelman L, Kennell JH, McGrath S. 1998; Landry SH, McGrath SK, Kennell JH, Martin S, Steelman 1998.
 Childbirth Connection, www.childbirthconnection.org; Coalition for Improving Maternity Services (CIMS), www.motherfriendly.org/; Lamaze International (www.lamaze.org); ICEA (www.icea.org)
British Columbia Perinatal Health Program
 Doulas: Making a Difference, video.