Monday, December 05, 2016

I'm continuing to review some of the most talked about topics of 2016.  In the next few blogs, titled "Year in Review", I will share findings, thoughts and resources for you, the birth professional, as well as resources for your clients.  If there is a topic you would like to see in "Year in Review" please email me at

Birth Doula/Postpartum Doula Care

Doula care worldwide is increasing in popularity, where popularity is both defined as public knowledge of the word and its meaning, and also the access and use of doula care both in the birthing process and in postpartum.  After nearly 35 years of research, this is a welcomed statement to make.  Current research in journals, particularly nursing journals (AWHONN), demonstrate the definite benefits to the laboring family and care providing team of
birth doulas.  From reducing the cesarean section rate through non-pharmacologic pain relief methods and the integration of upright/gravity positive frequent position changes, doulas provide the 1-1 care that (especially in the US) maternity medical care so frequently talks about, richly needs and from which huge benefits can be derived.

Postpartum doula care has been attributed to extended breastfeeding, easing of postpartum mood and anxiety disorders and an overall reduction of stress brought about by new parenthood.  With immediate and extension of breastfeeding comes better health for the new society being born, and a healthier society for tomorrow.  Postpartum doulas care today for the health of the community of the future.  This may prove to have significant effects on future health care studies.

One overall drawback to doula care is the lack of standardization in training and certification.  There are currently a myriad of nonprofit organizations, startup companies and small businesses who provide doula training and certification.  It is the opinion of this author that a standard, professional training and certification module would greatly enhance the acceptance of doulas as members of the health care team (much like nursing) as well as increase credibility in the lay community.  Standardization would also help eliminate the person who enters the profession of doula care with their own agenda.  Regretfully, these hidden agendas are brought forth after training and certification are complete and when the doula begins practice in their community.  It is then that negative agendas appear and the entire doula community may be labeled according to one doula’s rogue agenda.  This can happen in any segment of the medical community, however, if the doula is not an employee of a hospital or birth center, or not a member of an organization with a grievance policy, there is precious little that can be done to “save face” after an act has been completed.  Knowing the lengths that some individuals would go to promote their own agendas, this author sometimes doubts that a threat of suspension or withdrawal of standard certification or even licensure would thwart a doula’s rogue agenda.  We don’t know until we try.

Community based/hospital paid/volunteer

There are currently several ways to access doula care.  Doulas may be independent small business owners and operate within the community in which they live.  Most of their business is referral by “word of mouth” or perhaps low cost marketing such as business cards or self-generated brochures or flyers.  Cost of community based doulas generally vary with services provided, community cost of living, and years of experience of the doula.  Community based doulas may or not be trained by legitimate organizations, and may or may not even be certified.  Community based doulas may or may not carry their own malpractice insurance.  The thinking is that since the doula performs no clinical skill, the chances of them being included in a law suit are minimal.  To be on the safe side and to protect their personal and professional assets, some community based doulas do carry malpractice insurance.  Clients pay the doula directly, either by cash, credit card or even barter.  The doula is solely responsible for their own taxes. (Discussion of the decision to be certified has been addressed in an earlier blog:  )

More and more hospitals are bringing in doulas into their staff.  Generally, hospital based doulas are trained and certified by legitimate organizations, overseen by a doula director or manager, and evaluated year.  They may be included in the malpractice insurance of the hospital and should there be a grievance against them either by a co-worker or client, the doula director or manager would be the one to handle the grievance issue.  Payment to the doula is made by the hospital and general is a flat fee for service.  This service may include 1-2 prenatal visits, the length of labor, and 1-2 postpartum visits.  Clients pay the hospital in advance and the hospital is responsible for all taxes and fees, as in any other business.

Occasionally, a hospital based doula program can provide volunteer doulas for those in a specific population (for example, if they are conducting a trial to reduce cesarean rates in a given population) or if they are grant funded for a specific population. Volunteers may be asked to serve as doulas for a number of births in exchange for their training and certification.  Since training and certification through a reputable organization can cost upwardly of $500-$1200, this can be a win-win for a hospital serving a low-income population while also giving a new career to a person who would otherwise not be able to afford such quality training and certification!  This can also be a huge benefit for the community, as more and more doulas are brought in to the community for support.

Nurse labor support skills

Much has been published in the nursing literature about nurses being the perfect labor support person.  Who better to support the laboring mother and her family than the nurse who also has intimate knowledge of this woman’s medical condition.  Nurses are by definition caring and loving individuals.  It just makes good common sense.  It makes good common sense until you realize all of the other mandatory tasks that a staff nurse in L & D has on her plate on any given day.  Not only is she given 1-3 actively laboring patients, but there may also be a myriad of other non-patient related tasks (such as crash cart audits).  Today, nurses are also required to actively chart electronically on each patient.  This may be an easy task for those who are tech savvy, and quite the challenge for who are not technologically oriented.  All of this makes for nurses who are stretched emotionally and physically.

However, for those facilities who wish to give their nurses the non-pharmacologic pain relief knowledge to support physiologic births that is not taught in nursing school, organizations such as ICEA have special, one-day workshops (complete with nursing CEs) to provide this knowledge.  ICEA’s Mother Friendly, Evidence-based Labor Support Skills Workshop for nurses is a prime example of meeting the nurses’ needs almost before the nurse knew she had the need.  In this eight hour workshop, nurses not only learn the non-pharmacologic skills but also the science and rationale behind these skills.  Nurses can go back to their units and immediately apply their new skills ~ increasing nurse satisfaction, patient satisfaction and improve labor/birth outcomes!

Doulas still are the best way to provide physical, informational, emotional and practical support to expectant families with positive, statistic changing results.  Research has shown that doulas can positively impact length of labor, perception of pain, and reduced the incidence of interventions such as cesarean section.  

In the wise words of the late Dr. John Kennell, 
“If a doula were a drug, it would be unethical not to use it.”

For Further Review
  1. Aschenbrenner, A.P. et al. (2016) Nurses' Own Birth Experiences Influence Labor Support Attitudes and Behaviors.  Journal of Obstetrics, Gynecology and Neonatal Nursing.  Jul-Aug;45(4):491-501. doi: 10.1016/j.jogn.2016.02.014.
  2. Fortier, J. H., & Godwin, M. (2015). Doula support compared with standard care: Meta-analysis of the effects on the rate of medical interventions during labour for low-risk women delivering at term. Canadian Family Physician, 61(6), e284–e292.
  3. Kozhimannil, K. B. et al.  (2013). Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries. American Journal of Public Health, 103(4), e113–e121.
  4. Kozhimannil, K.B. et al. (2016) Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery.  Birth.  Mar;43(1):20-7. doi: 10.1111/birt.12218.
  5. Kozhimannil, K.B. et al.  (2014) Potential benefits of increased access to doula support during childbirth.  American Journal of Managed Care.  Aug 1;20(8):e340-52.
  6. Kozhimannil, K.B. et al. (2016) Disrupting the Pathways of Social Determinants of Health: Doula Support During Pregnancy and Childbirth.  Journal of the American Board of Family Medicine.  Vol 29. No 3. 308-317. Doi: 10.3122/jabfm.2016.03.150300.
  7. Roth, L. M. (2016) North American Nurses' and Doulas' Views of Each Other Journal of Obstetrics, Gynecology and Neonatal Nursing. Nov - Dec;45(6):790-800. doi: 10.1016/j.jogn.2016.06.011.
  8. Zielinski, R.E. et al (2016) The Value of the Maternity Care Team in the Promotion of Physiologic Birth.  Journal of Obstetrics, Gynecology and Neonatal Nursing. Mar-Apr;45(2):276-84. doi: 10.1016/j.jogn.2015.12.009.

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