Tuesday, December 29, 2009

Responses to Dr Abhijoy Chakladar - Part 2

Previously, I posted (by their request) DONA International's response to Dr. Chakladar.

Shortly before Christmas, I was contacted by Dr. Chakladar, who gave me the direct link to the British Medical Journal piece. Below, is the BMJ article with my contributions in blue italics. Special thanks to Desirre Andrews of ICAN for her contributions.

Encounter with a doula: is the system failing new mothers?

Anyone know what a doula is?" I asked in the coffee room. I was met with a roomful of blank faces. Earlier, during the morning obstetric meeting, a midwife told me that her patient had a doula. "A what?" I asked. "You know," she said, "a birthing partner." I didn’t know; anyway, isn’t that the job of the partner or the baby’s grandmother?

The word doula derives from the ancient Greek for "woman of service." Recently it has been used to describe experienced women who help mothers care for newborn infants; the role now extends to attending prenatal classes and the birth itself.

Taking a strong look at birth history throughout the world, there have always been at least 3 persons at a birth: the birth attendant (midwife or physician), mother and partner. Today, in our mobile versus traditional society, birth partners along with the pregnant woman are relatively uninformed about maternity care and the birth process. In the US, only 33% or less of expectant parents attend a prenatal childbirth class. So when an expectant mother (partner) want more personalized, continuous care that involves education, emotional support and physical support during a birth, she often turns to a doula.

On this occasion an epidural had been inserted as per the birth plan, and I was called to assess the patient’s analgesia, as she complained of discomfort. I found a missed segment and planned an epidural bolus with repositioning. The doula had been present since admission, as had the husband. Both the mother and father were confident and articulate, so I couldn’t help but wonder why they needed to pay for support.

Confidence and articulation cannot or should not be put together in the same category as informed about the birth process or hospital policies/procedures. The other piece to this puzzle is that the work of labor still needs to be done. With an epidural on board a labor is often turned over to technology lessening interaction with the mother as part of the birth. A doula is often well versed in how often a mother needs to change position for optimal fetal positioning, helping the mother stay in touch with the birth process, and keep her invested emotionally.

In my practice the mother is the principal focus, but I address the couple together, recognising their joint experience of bringing a new life into the world. I found myself disconcerted by the doula’s presence, as I was unfamiliar with her role. To whom should I direct my explanation? If I spoke to the doula and mother, would I marginalise the father? If I spoke to the couple would this be regarded as disrespectful to the doula? She was there, after all, at the express wish of the mother, her employer. I chose to speak directly to the mother—the patient. I gave the top-up and advised that she turn to lie on her side. At this point the doula interjected to say that the mother was comfortable as she was and asked whether repositioning was necessary. I said it was for the top-up to be most effective.

Any health care professional should address the mother/father/partner. The doula can be an advocate but should never be a voice during the birth unless she is the sole support of the mother and the mother cannot speak for herself. In this situation, the doula had definitely stepped out of her role as a doula, violating the Standards of Practice and Code of Ethics. It would be interesting to see if she was certified by a doula organization, what the name of that organization is, and what said organization’s Standards of Practice are.

While documenting the procedure I was informed that the patient had decided not to move. I realised my mistake. If the mother had asked the same question, I would have qualified my answer with a description of how epidurals worked and the effects of positioning on the spread of a local anaesthetic. As the doula had asked, I had dismissed her question without explanation, compromising my care. Failure to offer sufficient justification to the doula seemingly gave sufficient justification to veto my request to reposition. In this clinical situation the presence of a doula swayed the decision making incorrectly. In retrospect, I should have confirmed everyone’s roles and established ground rules acceptable to all involved on entering the situation.

Again, this doula clearly stepped out of her role. Though conversing with the doula would have been appropriate. Getting clarification could very well help her support another family in a better way in regard to epidural use and function.

Hired birthing partners are unregulated, not part of clinical obstetric teams, and therefore should not be involved in making clinical decisions. There is no nationally recognised certification for doulas, and it is possible to work without training. Courses are available for doula training; these claim to improve understanding of what parents expect from a premium service and options regarding birth plans; to reinforce the role of doulas; and to allow a brief experience of the childbirth process. The Nursing and Midwifery Council recognises doulas solely as emotional support for mothers and as unqualified persons who cannot substitute for registered midwives.

There are several international certifications for doulas including DONA International, the International Childbirth Education Association, and CAPPA (Childbirth and Postpartum Professional Association). These are US based organizations and I would encourage you to contact the National Childbirth Trust to see what organizations are in the UK. In no way are doulas to replace midwives as doulas are not clinicians. Doula as a birth professional is still in toddlerhood. Doula as an accompanying individual is not. Women of knowledge have attended other women throughout history as part of traditional cultural practice. A doula being part of the birth team can enhance the process for care providers, staff, and the family.

Doula organisations often cite a meta-analysis published by the Cochrane Collaboration that found an association between continuous birth support and risk reductions in regional anaesthesia, instrumental delivery, and caesarean section. Most importantly, it showed a 27% relative risk reduction in mothers reporting negative ratings of childbirth experiences. Although these are positive findings, is this not what midwives are employed to do?

Hospital-based midwives in the US practice similarly as physicians. So no, this is not what midwives are employed to do. Midwives are concerned with the clinical aspect. In the homebirth or birth center environment midwives have more latitude to offer more in depth support. Often the doula is with the family throughout most of labor and delivery, whereas the midwife no matter the birthing environment is not. Doulas, ideally, are not concerned with the clinical aspect of birth, but focus on the emotional, physical and informational support.

About 1000 doulas work in the United Kingdom, offering packages that include antenatal, labour, and postnatal visits and on-call periods for a charge of between £400 ( 440; $660) and £900. In the United States in 2005 there were an estimated 100 000 doula supported births. As the trend grows here, a cynic might ask 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 services. The next evening I encountered a former drug user in advanced labour, with three children already in care, and birthing alone save for a midwife who was caring for two labouring woman. Sadly it seems those who need emotional support most cannot afford doulas.

While I am not sure of the doula climate in the UK, I can tell you that many, many US doulas will do births free of charge, for a reduced fee, or barter. This is true for veteran doulas as well as newly trained doulas. As for 100000 (birth) doulas in US, this number is not validated. The main doula organizations combined in the US have approximately 10000 members, who may be antepartum, birth, and/or postpartum doulas.

I am disappointed by the real or perceived need for doulas. It is the medical and midwifery professions’ duty to support and advocate for mothers and families through a very special but potentially frightening experience. Traditionally, emotional support came from female relatives; more recently the modern father has stepped into this role. Partners, friends, and family—those who know the mother best—should provide this support. Sadly, this position cannot withstand chronic understaffing, shift work, midwifery care that is less than one to one, and European working time directives, making continuity of care impossible. Nor can it withstand single parenthood and increasingly detached nuclear families.

Again, I am unfamiliar with maternity practices in the UK, however I can tell you in the US that with the current (and persistent) nursing shortage, nurses, physicians or hospital-based midwives do not have the time to spend supporting individual clients through the entire birth experience. Due the availability limitation, nurses often pop in and out while the care provider is engaged with the patient maybe 30 minutes of the entire labor and delivery. Expectant parents feel the need for educated guides through a very confusing and sometimes hostile maternity climate. There is also the matter that doulas have been part of birth throughout history regardless of name.

As healthcare professionals we forget how much of an unknown the body’s processes are to the general public, that much of what we take for granted is a complete mystery to even the most confident and articulate lay people. The processes of child birth are new and anxiety provoking experiences, and what people fear most is the unknown. Combined with the often time pressured hospital environment and need for quick decisions, this takes control away from the individual. A lack of continuity in carers does not allow parents to develop trust in clinicians, as they find themselves having to start new relationships every 12 hours, diminishing the quality of communication. People seek some continuity in their support in stressful situations; perhaps doulas fill a gap in this market.

Doulas do, in fact, fill in this large gap in continuity of care ~ you are correct that beginning new trusting relationships of care providers (nurses) every 8-12 hours can be interruptive. It would be more helpful for physicians and midwives to promote prenatal childbirth education classes as was done in the 60’s and 70’s so that the body process of labor and birth is not such a mystery to either the expectant mother or her partner.

Is this a passing fad, or is there really a need for doulas? Either way, clinicians need to be aware of doulas, so that their service is not compromised by the presence of new people in clinical settings. This trend may be a sad reflection of failures in the delivery of medical and midwifery care, a sticking plaster concealing greater problems. Availability of this commercial service indicates that current social structures do not support pregnant couples adequately; healthcare professionals may not be able to support their patients as they would like to. Are we no longer able to make common sense decisions without asking a hired friend?

Nurses, physicians, midwives and other clinicians need to be educated fully about doulas, their scope of practice and code of ethics. They need to be aware of the positive contributions modern doulas make for labor/birth and during the postpartum period as well. While the need for doulas today may be a commentary of the failure of our social support system and desire for education during pregnancy/birth/breastfeeding, thank goodness doulas are available to fill that need. Most often the need is filled without conflict and better outcomes all around.

1 comment:

MBT said...

it is good
i like it