Why are women using doulas during childbirth?

With a growing trend for doulas acting as second birth partners during childbirth, Emma Sheppard asks what the role entails, where the boundaries lie between midwife and doula and why so many mothers are choosing to pay for extra help during labour…

“With anything else in life that you’re doing for the first time, you consult an expert or someone who’s gone through it before and you gather as much information as possible,” says mum-of-one Emma Wright. “So when I was pregnant, I felt like I needed somebody who was going to say, ‘it doesn’t have to be a live episode of Casualty’.”

Wright first came across the word “doula” when she was reading a Mumsnet book about pregnancy and both her and her husband liked the sound of having extra help during the labour and childbirth.

“My husband totally got it,” she says. “I think he felt relieved there would be that other person to share the stress.”

A doula (which comes from the Greek word for servant) is a non-medically trained layperson who assists a woman giving birth. It is said to be one of the oldest professions in the world – before midwifery became a recognised profession, it was an older woman from the community who was called on to help when mothers went into labour.

In 1902, the Midwives’ Act for England and Wales governed the training and practice of midwives and made it illegal for any unqualified person to act as a midwife. At the time, maternal mortality in the UK was at around 500 per 100,000 births, compared to 10 out of every 100,000 births today. Experts argue that this has also been because more women are now giving birth in hospital, where medical intervention is available if needed.

She was that constant focus there reminding me what I needed to do, while the midwives fussed around me

Yet despite the shift towards hospital births and the regulation of midwifery as a profession, pregnant women are still hiring lay women as doulas – and the rate is increasing. In the US, the Doulas of North America International have 7000 members. British mothers are embracing the trend too. Doula UK, a not-for-profit organisation, had 40 members when it was established in 2001. Now there are nearly 700. Chair Kicki Hansard has had 14 years of experience as a doula and says there still seems to be more than enough work to go around.

“I was busy back then and I’m still busy now,” she says. “Even though we have a lot more doulas, I still have a lot of enquiries. Most doulas are mums so it’s kind of a part time job. You can maybe do 10 births a year.” At £300-£2000 per birth, depending on where in the country you live and what’s included in the package – some will include hypnobirthing coaching or acupuncture for example – it’s not a get-rich-quick enterprise.

Catherine Stott says she regretted not having a doula for her son’s birth so when she found out she was pregnant with her daughter, she was determined to hire one.

“I found it really hard [the first time] to make decisions during labour. Originally I’d wanted a home birth and then that wasn’t going to happen. I didn’t think I wanted pain relief but I didn’t know the pros and cons and the midwives were being very vague when I asked about it. My husband just stood there, not really knowing what he was supposed to be doing.

“Second time around, it was a brilliant experience. She massaged me through my contractions, helped me to remember to breathe properly. She was that constant focus there reminding me what I needed to do, while the midwives fussed around me.”

Stott also hired a postnatal doula to offer breastfeeding support, and “just generally make sure I was ok”. She says she did have a community midwife but didn’t necessarily feel she connected with her in the same way. “If I had been depressed or miserable, I might not have told her about it… I would have been able to tell my doula.”

The doula supports mum by just being there, which might make her feel more confident to stick to what she wants and how she wants to proceed

Allison Tate trained as a doula in 2013 and says she “supports the women, their birth partner, their families… in whichever way they wish. We’re a guide to help navigate pregnancy, birth, early parenting and supporting women to have their voices heard.

“Continued support is really important… the really big thing is increased birth satisfaction. Women say they feel more at peace with their birthing experience. And that’s important for postnatal depression and for the babies too.”

Doula champions point to a Cochrane study, published in 2013, as evidence of the benefits. It covered 16 countries and more than 15,000 women, and found that “continuous support in labour has clinically meaningful benefits for women and infants”. Support was provided either by hospital staff (such as nurses or midwives), doulas, or companions of the mother’s choice (a partner, mother or friend, for example). Researchers found that this led to a reduced risk of caesarean or use of forceps during birth, a reduced need for an epidural or painkillers, a shortened labour and more satisfaction with the overall childbearing experience for the mother.

But the proven positives of continuous support during childbirth and postnatally do not explain why this is increasingly being given by doulas who are hired by expectant mothers, rather than midwives. Some suspect that it is another symptom of the overstretched NHS, and because mothers are not guaranteed a relationship with one midwife from pre- to postnatal care.

In a comment written by the Royal College of Midwives’ (RCM) chief executive Cathy Warwick in the Midwives magazine, she says: “there is a distinct possibility that the increasing use of doulas reflects growing pressures in the maternity services, with midwives unable to spend the time they would like giving women one-to-one support.”

Can we trust women to make decisions for themselves, or do we need an expert to tell them what to do?

Tate thinks that this has a lot to do with it. “We’re in a really complex maternity culture right now. There’s a lot of fear in the NHS [and] it’s very protocol driven, time driven, resource driven. There’s very little room for individualised care. It’s hard for midwives. Women are reaching out for support.”

The doula profession has not been without its controversy. According to the New York Times, in 2005 a hospital in the US banned doulas from entering the premises, and a 2006 survey of women in Alabama using doulas found that 44% described the relationship between their hospital nurses and doulas as “hostile, resentful and confrontational”.

In the Midwives magazine, Warwick refers to evidence of this animosity in the UK: “We have heard stories from around the country… [which] ranged from ‘doulas are wonderful’ to serious concerns being expressed, mainly around the role of the doula impacting on the role of the midwife, with the mother sometimes caught in the crossfire.”

Doulas are not required to undergo professional training, so standardised procedures cannot be guaranteed. However, Hansard says doulas should never obstruct medical professionals at the birth. Members of Doula UK, who are listed in a directory on the site, must do an approved course (which ranges from four days to nine months) and are supported by a mentor through their first four births, before they are considered registered.

She adds: “doulas don’t give advice, we give information. I might say to my client: ‘do you have all the information to make the decision?’ rather than saying the midwife or doctor is wrong.”

However, she agrees that that support can empower the mother to stand up for herself, which might cause issues with the medical staff. “The doula supports mum by just being there, which might make her feel more confident to stick to what she wants and how she wants to proceed. And that can make it a bit more difficult for a midwife or obstetrician to do what they feel is the best way forward… [But] we are all a team. We are all working towards the same goal.”

For Hansard, it comes down to one question: “Can we trust women to make decisions for themselves, or do we need an expert to tell them what to do?”

Wright’s doula didn’t end up being with her for the birth – she woke up in the middle of the night thinking she had food poisoning and her husband delivered their daughter on the bathroom floor – but she says that the support her doula gave her before and after was invaluable.

“Even though my doula wasn’t there and it wasn’t the candles and water situation I’d had in my mind, just having the knowledge that it was going to be ok, that positive frame of mind, really helped.

“It’s not a cheap thing but you’re paying for someone’s services. They’re going to be there with you at one of the most important experiences of your life. It’s not that money is no object, but we saw it as an expense that was well worth it. I still do.”