CLINICAL OBSTETRICS AND GYNECOLOGY Volume 44, Number 4, pp 692–703 © 2001, Lippincott Williams & Wilkins, Inc. Doulas: An Alternative Yet Complementary Addition to Care During Childbirth MARTHA A. KAYNE, CNM, MN, MARY BETH GREULICH, CNM, MSN, and LEAH L. ALBERS, CNM, DrPH University of New Mexico, School of Medicine, Albuquerque, New Mexico The doula has evolved in recent years as a They understand the intimate nature of birth welcome and sometimes necessary addition and provide the “softer, quieter, gentler, to the health care team. Cost-cutting mea- more sensitive nurturing qualities of ‘moth- sures have increased provider-to-patient ra- ering the mother’.”1 Most important, the tios, and perinatal technology has distanced doula stays with the woman throughout la- nurses from the bedside of women in labor. bor, beyond the confines of any shift, mak- Nurses rarely have the opportunity to stay ing the woman and her family feel cared for with one woman throughout labor and birth. and never alone. Regardless of the response On the contrary, a laboring woman is the of the mother to labor, the doula is encour- doula’s sole responsibility. The word aging, provides comfort measures, and re- “doula” is defined as a person who is “in the sponds to each of the mother’s differing service of” the woman in labor. Usually, a needs. She explains and clarifies medical in- doula is self-employed and is hired by the terventions, thereby decreasing the laboring laboring woman. As such, she is not re- family’s anxiety. By her presence and com- stricted by allegiances to a facility or the forting touch, the doula creates calmness medical establishment. Doulas are usually and the essence of safety.1 women who have had a baby and are able to empathize with another woman in labor. Historical Perspective Historically, other women have attended ex- Correspondence: Martha A. Kayne, CNM, MN, Univer- pectant mothers at birth. Typically, it was sity of New Mexico, Nurse-Midwifery Division, 2211 Lo- mas Boulevard NE, ACC-4, Albuquerque, NM 87131– one’s mother and/or other older female rela- 5286. tive who were present to assist. Studies by CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 44 / NUMBER 4 / DECEMBER 2001 692 Doulas During Childbirth 693 anthropologists have found that in 98% of birthroom and, in some cases, even thrust observed societies, an older woman was the into the role of “labor coach.” Fathers began birth companion.2 Women have nurtured, playing a major role in directing the laboring comforted, and advised each other and have woman’s “behavior.” Experiencing the sat- applied skills learned from their own birth isfaction of birth became a goal in itself for experiences. Men were rarely a part of child- many families. It became apparent that fa- birth. ther-supported childbirth, rather than being In the early 1900s in Europe and North a negative event for hospitals and physicians America, birth moved from the home to the who feared increased scrutiny, was actually hospital, and many of these skills and tech- positive—on the labor itself and on the re- niques were lost in the medicalization of membrance of childbirth for the parents. In childbirth. Family members were barred 1973, only 27% of hospitals were permitting from attending births. The traditional role of fathers in the delivery room; by 1983, 79% women at birth disappeared, and men, in of these hospitals encouraged fathers to par- their role as physicians, took over. Addition- ticipate in labor and delivery.1 ally, pain relief in the form of pharmacologic Though men have been increasingly pre- analgesia/anesthesia removed the laboring sent during childbirth, their role as the pri- woman from the picture by leaving her mary support person has been criticized. Re- asleep or out of control. Hours after birth, a search has shown that today, too much is ex- nurse would bring a newborn that the mother pected of men at childbirth.4,5 Fathers find it could not remember delivering. The role of difficult to be objective. The stress of seeing nurses had shifted from providing nurturing a loved partner in pain, anxious, making un- care to performing more highly valued accustomed sounds, and exhibiting dramatic medical tasks, often for more than one behaviors can be overwhelming. Anticipa- woman in labor. tion, excitement, concern, anxiety, and fear The natural childbirth movement of the all intermingle so that the father cannot re- 1950s and 1960s resurrected interest in natu- main emotionally detached enough to meet ral childbirth and the desire for a supportive his own and the mother’s needs.4 However, companion during labor. With extended the father’s presence is important for the families no longer a key part of Western life, emotional connection of the couple to each a nurturing female family member was un- other and to the baby. Involvement of a available, and women from the mother’s doula can enhance the father’s role during community did not have the knowledge and birth.1,6 The father is never left as the sole, experience of their own mothers. Grantley isolated, responsible person caring for the Dick-Read,3 one of the earliest proponents laboring woman, a role he is sometimes ill- of childbirth education, wrote about effec- equipped to perform.4,7 Recognition and tive ways to minimize childbirth pain. It was validation of the father’s right and need to be through his principle of the fear–tension– present at the birth of his infant is not only pain cycle that the benefits of preparatory compatible with but also enhanced by the education and support during labor gained presence of a doula.6,8 The doula provides interest. The father-to-be was advocated as support, reassurance, comfort, and informa- the likely choice to provide this support. tion not only to the laboring woman but also In the 1960s, hospital policies did not rou- to her partner, improving the birth experi- tinely permit laboring women a companion. ence for all involved. However, by the late 1970s, the concept of family-centered care was established, and an STRESS PHYSIOLOGY emphasis was placed on keeping a family to- Whereas the physiologic changes and com- gether during the labor and delivery process. plications of pregnancy have been studied This meant that fathers were allowed in the extensively, less attention has been directed 694 KAYNE ET AL toward the impact of emotional stress on the restore equilibrium. Fear and stress cause mother and the outcome of pregnancy. The the adrenal medulla to secrete epinephrine available evidence suggests that uncompen- and norepinephrine. Kelly10 determined that sated stress may be linked with adverse birth these hormones, especially epinephrine, in- outcomes. fluence uterine activity in response to fear. The childbirth environment itself is stress- Zuspan11 advanced this work by finding that ful and elicits the stress response in the norepinephrine caused uncoordinated and mother. Multiple factors contribute to creat- ineffectual uterine activity, and epinephrine ing stress, such as the unfamiliar hospital diminished uterine activity during both spon- setting and staff. Two studies, reported by taneous and oxytocin-induced labor. Leder- Keirse et al,9 found that a woman giving man et al14 found that women in active labor birth encountered an average of 6.4 unfamil- who reported anxiety had significantly in- iar professionals during labor; in a teaching creased levels of endogenous epinephrine, hospital, as many as 16 people during 6 and these were associated with decreased hours of labor were reported. In an environ- contractile activity and longer labors. Fur- ment like this, no one person can connect ther research found a relationship between with the mother and provide the emotional measures of epinephrine, observed stress stability necessary to cope with labor. and anxiety scores, and fetal heart rate pat- Common policies and procedures such as terns, thus demonstrating the link to human insertion of intravenous lines, restriction of fetal well-being.15 fluid and foods, vaginal examinations, re- Pain and anxiety have been proven to be striction of movement, fetal monitoring, among the several influences that lead to en- augmentation of labor, epidural analgesia, dogenous release of catecholamines. A and the possibility of an operative outcome moderate amount of maternal stress during all contribute to the stress response. The la- labor is desirable to stimulate the appropri- boring woman is often left alone to deal with ate maternal and fetal adrenal cortical and the fear and pain of labor and the anxiety in- adrenergic responses.14 In animal studies, duced by a mechanized clinical environment the extent to which stress states during preg- and multiple unknown attendants.9 nancy or labor could lead to sufficient cate- The association between acute maternal cholamine release to reduce intervillous anxiety and disturbances in the progress of space perfusion is unclear. Lederman’s find- labor has been suggested in studies of hu- ings support the hypothesis that under nor- man and animal mothers.10–15 Circulating mal clinical conditions, several types of pa- catecholamines may be the mechanism by tient anxiety/stress are associated with in- which fear and anxiety influence the course creased catecholamine levels and that of labor. The cycle of fear leading to in- excessive anxiety and epinephrine are re- creased myometrial tension and pain, thus lated to the increased duration of labor and creating more fear, was the basis of Dr. adverse fetal conditions in the human Grantley Dick-Read’s childbirth education mother. Use of stress-reduction techniques philosophy, and its alleviation is a major and modification of the childbirth environ- goal to help achieve a successful birth. ment could obviate the need for certain Largely empirical at the time, his thesis has childbirth interventions, such as augmenta- been used to explain the cause of conditions tion of slow labor.