Photo by Sandra Seitamaa

Midwifery Today, Issue 141, Spring 2022.
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“You are assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. You must take the leap, leap so the mother is helped yet still free and in charge. When the baby is born, the mother will rightly say: we did it ourselves!”
—Tao Te Ching, 2500 Years Ago

Throughout history, women have been supported during pregnancy and birth by laywomen, i.e., mothers, grandmothers, aunts, sisters, and friends. It wasn’t until birth moved from home to hospital that women were forced to birth alone, surrounded by technology and medical staff rather than loving companions. Hospital birth became standardized and impersonal, with an appealing promise of safer, easier births, as well as a sign of status. With the move from midwife-led homebirths to medical-model hospital births came a discontinuity of care and an indifference to the birth experience.

Eventually fathers, sometimes grudgingly, were allowed to accompany their wives for the birth of their child but were often not prepared to guide their partners through the maze of decisions and pressures sometimes exerted by institutions. As modern birth practices evolved, the idea of trained, non-related birth support people—doulas—became a popular way to personalize and humanize an otherwise cold and unsupported process. For families not able to have a midwife-led birth, doulas can stand in as a source of information, continuity of care, and comfort.

There are many paths into doula work. There are training and certification programs, such as Childbirth International (CBI) and Doulas of North America (DONA), which range in price from $500 to $1500, and include a scope of practice and/or code of ethics for their graduates. Some people evolve organically into the role of doula by attending the births of friends or family. Others take training programs, such as Gloria Lemay’s doula training or rebozo technique classes, but choose not to certify. Regardless of the path, all doulas have the same goal: to guide a family toward their best possible birth.

It is more common to find doulas working with families in hospital birth settings where nurses are unable to provide meaningful labor support. Birth centers often employ doulas to provide non-medical emotional and physical support, allowing the midwives to serve several couples at a time and be rested. Some hospitals have volunteer doula programs that provide doulas to families who, otherwise, wouldn’t have one. San Francisco General Hospital has provided doulas to their clients since 1993. Doulas have formed groups that provide services to low-income, marginalized communities, so that finances aren’t an obstacle to their birth experience. There can be a doula for every family.

Some homebirth midwives incorporate doulas into their practices. Midwife and doula will, sometimes, alternate prenatal visits to reinforce information and form a bond with the family. The doula will teach comfort measures and optimal birth positioning. Doulas can arrive during early labor to give support before the midwife’s skills are needed and sometimes assist with the birth tub. While the midwife is focused on the health and safety aspects, doulas focus on emotional and physical comfort. A good relationship between midwife and doula greatly enhances the birth experience for the homebirth family.

What do doulas actually do? Prenatally, they provide information that is often glossed over by Ob/Gyns and educate couples about choices, decisions, procedures, and their rights as patients. They teach physical comfort measures, such as massage and rebozo, so the partner is armed with what he or she needs to be an active, supportive participant. Doulas prepare the couple for what they can expect in the hospital so they can plan for informed consent. During labor, a doula can provide constant physical and emotional support; suggest positions; run for water, snacks, and warm blankets; answer questions; relieve the partner; keep the environment calm and conducive to a gentle birth and provide whatever the couple needs in the moment. Most of all, doulas try to be invisible because they know that the experience belongs to the birthing family.

There are things that doulas should not do. Doulas shouldn’t make decisions. Their role is to inform their clients so they can make their own informed decisions. Doulas may act as a communication bridge between their clients and the hospital staff but should not speak for them. It’s important that doulas “stay in their lane” when working with staff or midwives. Everyone has a role and harmony is essential. When answering questions from their clients, doulas should not impose their opinions but provide evidence-based, balanced information. Doulas are not medical personnel; their services are limited to non-medical care only.

Ultimately, birthworkers at every level have a common mission: They dedicate their time, heart, and skills to improving birth outcomes for every family they serve. Doulas contribute to this mission by humanizing and personalizing birth for families of all kinds. Perhaps, someday, doulas won’t be “extra”; they will be a regular and integral part of every birth.