A doula is a professional trained in childbirth who provides emotional, physical, and educational support to a mother and her birth partner during pregnancy, birth, and postpartum. They do not have any formal medical training and do not perform any medical procedures. There are doulas that specialize in every type of birth, from home birth to a planned cesarean at a hospital. There is substantial growing evidence on how doulas positively impact births. But do you need a doula? With the benefits are downsides, like the additional cost. This article examines the evidence on having a doula, how they advocate for you and work with your OB/GYN or midwife, and how they support your partner in being your primary support during labor. Plus, get tips on how to find a doula that is the right fit for your family.
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What is a Doula?
The word doula means “servant” in Greek. A doula is a broad term that can describe someone who provides a variety of support. Typically doulas are referred to as people who provide support for labor, birth, and postpartum. Some doulas are full-spectrum, covering scenarios like fertility and trying to conceive, miscarriage, and abortion. Some doulas specifically support transgender or gender non-conforming parents. There are even end-of-life or death doulas who support people at the end of their life.
Birth and Postpartum Doulas
For human history, women had support from other women in their community during and after birth. This changed, especially in countries where births moved to a hospital setting. In the 1960s, the role of a doula was created within the natural birthing movement. A birth doula is a professional trained in childbirth and who provides emotional, physical, and educational support to a mother and her birth partner while they are expecting. A doula is trained to be your support person and advocate. A postpartum doula focuses on the days and weeks after your baby is born to support you and your family.
Doulas have training and experience, but there is no universal certification or licensing program for doulas. There are hundreds of different programs that train doulas, and they all vary on the amount of training and experience needed.
DONA (Doulas of North America) International is the largest organization that offers a doula certification. DONA requires a workshop that is at least 16 hours of instruction. You need to attend a childbirth education class. You also must provide continuous in-person labor support for a total of at least 15 hours over three births. Plus, you must submit evaluations from the care providers at those births. DONA International certified doulas are required to recertify every three years. They need to maintain continuous membership in DONA International. They must complete 15 hours of continuing education or meet an alternative requirement demonstrating that they are continuing their education.
Since there are no state or federal certification or licensing requirements, certification is optional but does show that a doula went through some formal training.
There is a wide array of services offered by doulas, and the scope of the services they offer will differ depending on the doula. Doulas truly are a jack of all trades and can provide support in various ways, both emotionally and physically.
Emotional support can include listening to you, whether it is to vent frustrations or voice your preferences for birth. Doulas also serve as your advocate and assist in facilitating communication between you and your care provider or other medical staff. They can assist in providing you with information on interventions and birth procedures and discuss your options. A doula can give you reassurance and encouragement that you can get through labor and birth. They can talk you through different coping techniques like breathwork, visualization, or position changes.
Although doulas cannot perform medical procedures, they can be hands-on during labor. Physical support during labor can support your weight in a squatting or standing position, using a rebozo to sift your belly or take some pressure off your back. They can provide counter pressure to alleviate some discomfort in your backs or hips. A doula may have tools like a birthing ball or stool for you to use.
Typically a birth doula will meet with you and your partner at least once, if not a few times before your labor. They are on-call and will be present for your entire labor. After your labor, there are at least one, if not multiple, visits. Doulas usually offer email, text, or phone support throughout your pregnancy and for some period postpartum. There are many variations of how much access you can have to your doula and when. Since every mother is unique, many doulas will put together a package with the services and access that you want.
Some of the specific services may include:
- Education about pregnancy and birth
- Assisting with the creation of your birth plan
- Belly casting
- Henna belly designs
- Mother blessings celebrations
- Prenatal massage
- Prenatal Yoga
- Sibling support if you have older children
- Rental of birth pool or TENS unit
- Placenta encapsulation
- Emotional support for processing your birth postpartum
- Recommendations for healing after birth and comfort measures
- Belly binding
- Parent education
- Newborn care
- Babywearing education
- Light housework, errands, or childcare
- Assisting siblings transition with a new baby
- Planning for returning to work
- Referrals to other professionals like lactation consultants, support groups, and other professionals outside of their scope
Doulas have training and experience in birth. They do not have any formal medical training and do not perform any medical procedures. A Doula is someone you would have in addition to an OB/GYN or a midwife, but they would not replace your primary care provider.
Since doulas vary in their education, expertise, and experience, their prices also span a wide range. You can expect to pay as little as $500 up to over $3,000 to support a doula. These prices also vary based on location, demand, and the services offered. Some doulas may offer sliding scale pricing based on your income.
It would be worth contacting your health insurance company to find out if they would cover some of the cost of a doula. If they do, find out if there are any specific certification requirements they must meet and what amount of services would be covered. Three states (Oregon, Minnesota, and Indiana) reimburse for doula services through Medicaid. More legislation is likely coming that would expand coverage and access to doula support. Some community-based doulas focus on lower-income and underserved communities.
The services provided by a doula include so much more than only being present for your birth. Most doulas offer access to them for the duration of your pregnancy and after you have your baby. Plus, they are on call around your due date to drop everything and be by your side for the entire duration of your birth. If you feel like a doula is not an option due to your financial situation, please check with your care provider and the venue where you plan to give birth. You may be able to find a volunteer doula program in your area.
The Evidence on Doulas
There is substantial growing evidence on how doulas impact births. The most comprehensive evidence comes from a Cochrane Review on continuous support for women during childbirth. This included 26 trials involving 15,858 women. The trials came from 17 countries, all in high and middle-income settings. They found that women with continuous support were more likely to have a spontaneous vaginal birth, meaning they did not require an induction. Women with continuous support were less likely to use pain medication, have an instrumental vaginal birth, a cesarean birth, or a baby with a low five‐minute Apgar score. Continuous support was associated with shorter labor. The mean length of labor in the continuous support group was, on average, 0.69 hours shorter. Women with continuous support were also less likely to report negative ratings of or feelings about their childbirth experience.
This is all good news in support of using a doula. No research is ever perfect and continuous support in the studies included in this review included doulas, a member of hospital staff, or an untrained partner, family member, or friend. As interest in doulas continues to increase, we should expect to see more research and data in the future.
Continuous support may be one of the most important reasons to support having a doula. The American College of Obstetricians and Gynecologists has acknowledged that continuous labor and delivery support has been shown to reduce cesarean birth rates.
Depending on your care provider and the setting you give birth, you may not have continuous support for the duration of your labor and birth. Many practices have numerous midwives or OBGYNs, and you may not see the same provider at each prenatal appointment or know who the doctor or midwife on call will be when you go into labor. Having a doula will ensure that you will have continuous support for the duration of your labor.
More Parents are Hiring Birth Doulas
In the past, doulas primarily attended out-of-hospital births. Today, doulas are becoming more common in all birth settings, even in major hospitals. According to one survey from 2012, Six percent of women reported doula care during birth. Women supported by doulas had lower odds of a cesarean.
In another survey done in California in 2016 found about 9% of mothers used a doula. 57% of mothers expressed an interest in having doula support in a future birth. While this is only in California, we can be sure that the use of doulas is increasing.
Acting as Your Advocate for Any Type of Birth
There are doulas that specialize in every type of birth, from home birth to a planned cesarean at a hospital. Any birth could benefit from the inclusion of a doula. The primary responsibility of a doula is to you as their client. Any organization that certifies doulas has codes of conduct and ethics that doulas need to uphold. If you independently hire a doula, they serve you, not the hospital or birth center, and not your doctor or midwife. They will need to communicate with other providers and navigate procedures and protocols where you give birth, but their only obligation is to you.
In addition to being physical and emotional support, they can also assist with sharing education and information, ensuring you have the information you need for true informed consent, and advocating for you, your partner, and your baby. Doulas don’t have competing interests from hospitals or birth centers. Their only focus is you. The value of a doula goes beyond being by your side at birth. They are a trusted member of your team throughout your pregnancy and after your baby is born.
If you know you have a cesarean birth discuss what that looks like with your doula and find out if and when they can be present to support you and your partner. Many hospitals will only allow one person, usually your partner, to be present during the cesarean surgery. A doula can still be there to support you and your family before and after the surgery.
If you are planning to have your baby at home or in a birth center, your midwife may not be able to transfer with you if you transfer to a hospital. The majority of doulas will accompany you and your partner to a hospital. Having a doula can ensure that you receive continuous support, even if your birth plans change.
COVID-19 and a Virtual Doula
COVID-19 presented many challenges to doulas, and many hospitals and birth centers were not allowing doulas to attend births. Some expecting mothers had to choose between having their partner or their doula in their labor. Over the last year, some doulas have figured out how to make a virtual doula work. When writing this article (June 2021), birth settings in the United States are welcoming doulas, but many still offer a virtual package at a reduced cost as an option.
A doula can consult with you over virtual meetings leading up to your labor and be present via a video call during your labor. Rather than having an extra person in your room, you have a phone, tablet, or laptop with your doula on the screen. Virtually they can still be there for emotional support, help direct your partner to assist with some of the physical needs like applying counter pressure, or suggesting you try a different position. For more information on using a virtual doula, see this article.
Can Your Partner Act as Your Doula?
A doula is bringing a lot of training, knowledge, and experience to your birth. One of the many roles of your doula is to support your partner in the role you want them in during labor and birth. A doula does not replace your partner as your primary support during labor. They will offer support and encouragement for your partner to fulfill the role they want in your labor. A doula is taking care of the little details like making sure you are staying hydrated and making sure other members of your birth team are respecting your preferences. When all those things are taken care of, it frees up your partner to be by your side and support you in the way you need them. If you do not have a partner to be by your side during birth, a doula can be an invaluable addition to your birth team.
Finding a Doula
The first step you should take in exploring options for doulas is to ask for recommendations. Check with your doctor or midwife, hospital, or birth center for recommendations. Ask friends or family who have used doulas if they would recommend their doula.
Next, you may also want to search online. A Google search of “doula [your city]” should bring up lots of options. A great website called Doula Match allows you to see and compare doulas in your area. You can see how long they have practiced, how many births they have attended, what services they offer, their certifications, and their price range.
Questions to Ask
Once you have a list of prospective doulas to reach out to contact them to find out more, the first question is likely if they have availability around your due date. From there, you can ask any question you feel would help determine if they are the right fit. Generally, you want a doula whose philosophy matches yours and who can support you in the birth you want, in the setting you are planning to give birth. A fundamental question to start could be: I am planning a hospital birth with an epidural. Is that something you can support? Or, I am planning a non-medicated birth with a midwife at my home. Is that something you have experience with? Here are some additional questions you may want to ask:
- What type of training have you had?
- Are you certified? If so, through which organization?
- How long have you been a doula? How many births have you attended?
- What do you include in your doula services?
- What is the cost?
- Do you have a backup in the event you are unavailable?
If there is anything important to you or that would help you determine whether this doula is the right fit, please ask. You could choose to ask if they have received the COVID-19 vaccine, or whether they are up to date on other CDC-recommended vaccines for health care workers.
Please have a call or meeting with a few doulas to explore your options and get a feel for how different doulas compare. Choosing the right doula for you may have as much to with your gut feeling as it does with comparing certifications or years of experience. The most important aspect of a doula is that it is someone you are comfortable with and that you feel will support you in the birth you want.
It is essential to voice your vision of the labor and birth you want. A doula who already has some experience with a similar birth may be a better fit. As an example, if you are planning for an unmedicated birth in a hospital setting, a doula who has only attended home births may not be the right person to help you navigate in a hospital setting.
If you find a doula who you love but want a service they don’t typically offer, ask about it. If their package includes add-ons that you don’t want, ask if you can reduce the services and the price to fit your needs. If you are having trouble financially, ask if they offer any discounts based on income or ask for discounts if you or your partner are in the military. Doulas are some of the most compassionate individuals and are excellent at tailoring their services to fit your needs and supporting you in the way you need.
Before You Hire a Doula
Before you sign a contract and put down a deposit, you should do a few things before hiring a doula.
Be open and honest about the birth experience you want, and make sure your doula will support your preferences. Even more critical, confirm your doula can remain supportive even if your preferences change.
Include your partner in meeting with a doula and selecting the one that is the right fit for your family.
Get clear on what they include and what they do not include or offer for an additional cost. Make sure you know the total price, when payments are due, and the cancellation policy.
Know when you can contact them and how quickly you can expect a response.
Read the entire contract before signing and if you have any questions, always ask.
Do You Need a Doula?
A doula can bring a lot of value to your birth experience and is an evidence-based asset to your birth team. Do you need a doula? The short answer is no. The longer answer depends on what you are trying to accomplish and what benefits you are seeking.
Most births have multiple support people present. In a hospital, you have nurses present in addition to your midwife or OBGYN. In a birth center, you may have more than one midwife present. It is possible you could have interns or other midwives, doctors, or nurses, who are in training and are available to assist you in your birth or act in some ways in the capacity of a doula. One benefit of a doula is that they can support you at home before going to the birth center or hospital. Plus, with a doula, you get continuous support.
If you are planning an unmedicated birth, you may benefit from additional support. Without pain medication, it can be challenging to cope with contractions, and the more tools you have in your toolbox, the better. A doula is evidence-based to minimize interventions.
If you and your partner are comfortable advocating for yourselves and are not afraid to speak up, fantastic. It can be challenging to advocate for yourself and stand up to medical professionals, especially when you disagree or feel like you are not being heard. If you could use some assistance in advocating for yourself, a doula can be helpful.
If the thought of having a doula does not appeal to you, that’s okay. I encourage you to explore this option and consider all the ways a doula may be beneficial. If you are limited financially find out if there are free or low-cost resources available to you.
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