NY Times: And the Doula Makes Four

And the Doula Makes Four

By PAMELA PAUL
Published: March 2, 2008

LIKE any other conscientious, organic-fruit-buying expectant mother, Pamela Myers knew what she wanted from her childbirth experience. And, as is the case with growing numbers of women, that meant hiring a doula ? the word means ?servant? in Greek ? to help during labor.

EXTRA CARE Mary Beth Harris, a doula based in Falls Church, Va., works with a client, Heather Allen.

?I wanted a natural, unmedicated birth,? said Ms. Myers, whose daughter was born in 2004. ?The doula was supposed to be my advocate at the hospital and help us carry out our birth plan.?

At first, Ms. Myers, now a 36-year-old mother of two in Glencoe, Ill., was thrilled with her doula, who doubled as a prenatal massage therapist. ?She was earthy yet grounded, and really knowledgeable,? she said.

Then labor began ? and went on and on ? and Ms. Myers?s opinion took a nose dive. Though the doctor recommended that Ms. Myers receive intravenous fluids to hydrate her, the doula, eager to avoid medical intervention, insisted that Ms. Myers ignore the suggestion, causing her contractions to spike.

Then ?she urged my husband and me to take a shower to ease the pain,? Ms. Myers said. ?I told her I didn?t want to, but she was adamant.?

Dripping wet, freezing and in bone-shattering pain, Ms. Myers said she seethed in silence. When she ultimately chose an epidural, her doula walked out. ?She was so set on my having a natural birth, she offended me, she offended the nursing staff, she offended my O.B.,? Ms. Myers said.

In an era of nurse shortages and high Caesarean rates, doulas and lactation consultants can be godsends for many women. Indeed, multiple studies show that a doula?s presence during childbirth leads to shorter labor, less medical intervention and a happier experience.

Similarly, lactation consultants are often necessary for mothers having difficulty breast-feeding. Overwhelmed nurses don?t always have the time for one-on-one instruction, and because formula use peaked in the 1970s, a mom?s own mother may be ill-equipped to offer advice.

But the increased popularity of doulas and lactation consultants has also led to more conflict ? not only with parents but doctors and nurses as well.

There are no national statistics on the phenomenon, and few women readily admit to doula discord. But according to a 2006 study of women who used doulas in Alabama, 44 percent of women described the relationship between their hospital nurses and doulas as hostile, resentful and confrontational.

At Reston Hospital Center in northern Virginia, disputes became so common that in 2005, the hospital banned doulas. ?From a nursing standpoint, too many crossed a line and interfered with my job,? said Sarah Baxter, a registered nurse and director of labor and delivery at Reston.

The American College of Obstetricians and Gynecologists has issued no official statement on doulas. Dr. Sarah Kilpatrick, chairwoman of the academy?s committee on obstetric practice, said in an interview that doulas can be helpful, but ?occasionally you have someone who attempts to interfere with the medical aspect of delivery.?

When 33-year-old Melissa Malka?s twins were in the neonatal intensive-care unit after being delivered at 33 weeks, a lactation consultant urged her to have tubes delivering formula through her babies? noses removed in favor of an intravenous feed to deliver nutrients, against the advice of her neonatologist. Intravenous feeds carry a high risk of infection for premature babies, but some lactation consultants fear that babies will develop a taste for formula and then reject breast milk.

?She was so intent on avoiding formula,? said Ms. Malka, from Olney, Md. ?I was very upset with her, but that?s their standard ? breast is best.?

Pumping around the clock with no milk to show for her efforts, Ms. Malka sought the help of four lactation consultants, but they couldn?t remedy the problem. When she consulted her obstetrician, she finally learned that she was unable to produce prolactin, a hormone vital to milk production. ?You would hope that L.C.s would be well versed in this type of thing since they?re focused purely on the breast,? Ms. Malka said, using the shorthand for lactation consultants.

The breast-only mentality can also put off today?s participatory husbands. Kenneth Cain, a 42-year-old writer in New York, said his wife?s lactation consultant was ?a nightmare.? In December, after he and his wife decided supplementing with formula for their one-month-old baby might not be such a bad thing, they turned to a lactation consultant for advice. ?All we got was this ideological diatribe on the merits of breast-feeding,? he said. ?It was like talking to a Marxist about an international trade deal.?

Doulas can be equally doctrinaire. ?There are doulas who really do not appreciate when women get medication,? said Mary Beth MacKinnon, a doula based in Falls Church, Va. ?I know some doulas who will not take on clients who are thinking of having an epidural.?

Mary Beth Harris, also a doula in Falls Church, has turned away two clients for precisely that reason. ?I choose to work with women who are striving for a natural birth because that?s where my passion and training lies,? said Ms. Harris, whose training was as a Bradley-method childbirth instructor, which emphasizes natural birth with intensive support from the husband.

?I?m a firm believer in the natural process,? she said, ?and in my idealism as a birth worker, I see this as my contribution to helping change the world.? In both cases, Ms. Harris referred the women to another doula.

Doulas contend that doctors and nurses aren?t always cooperative. Penny Simkin, a founder of Doulas of North America, has been a doula for 40 years, but she says, ?When I walk into a hospital where the nurse doesn?t know me, I still experience dismissal: ?What is she here for? Why does the woman think she needs someone else to protect her?? ?

For Mary Sanderlin, a doula who became a labor and delivery nurse in St. Paul, Minn., problems usually arise when doulas act outside the scope of their practice. ?As a doula, I certainly felt there were times when the medical staff weren?t being transparent about their wishes,? she said. But a good doula ?can force the medical staff to come clean about certain interventions.?

One major source of conflict is an absence of standardization and oversight, said Maureen Corry, executive director of Childbirth Connection, a nonprofit research and advocacy group that promotes maternal care. Between 1994 and 2005, the number of doulas certified by Doulas of North America grew to 5,842, up from 750. But a doula requires no certification ? anyone can be a doula, regardless of training.

Similarly, since 2003, the number of lactation consultants certified by the International Board of Lactation Consultant Examiners, which requires 2,500 hours of practice and 45 hours of course work, has increased 15 percent to nearly 9,000. But most consultants are not that well trained. Dozens of groups offer certification after completion of one- to five-day courses, and there are at least six different acronyms signifying lactation credentials. How can a sleep-addled mother differentiate among a C.L.E., a C.B.E. and a C.L.C.?

Though childbirth and breast-feeding seem like the most natural of acts, the complexities that arise ? from emergency C-sections to inverted nipples ? demand a great deal of training and experience. ?People laugh when I tell them I?m going to a weeklong conference on breast-feeding,? says Angela Love-Zaranka, a lactation consultant also certified by the board. ?But a mother may have had breast-reduction surgery or a baby may have Down syndrome, and you need to know how to deal with that.?

As Jessica Sacher, a registered nurse and lactation consultant at U.C.L.A. Medical Center, said: ?I don?t think anyone is out there deliberately trying to deceive mothers out of malice. But parents have to do the same amount of due diligence as they would when seeking a pediatrician.?

Interesting! Like most things in life, I think there's a balance.

I haven't used a doula so I'm not in a great position to post here but I will post what I would expect my doula to do. Primarily I would see her role as LISTENING to me and my wishes. Taking my last labour as an example, I would have briefed her that I would like to go natural as much as possible BUT I would expect her to be supportive if I had tried everything and all things considered, had decided to use drugs.

My labour was very long. OK, officially I may only have been in labour for a stock standard 16 hours or so but the pre-labour killed me. By the time I went to the hospital I'd had 7 hours sleep in three days and my DD was posterior. Now, I know that a lot of people would say that posterior babies take longer to come out and you just need to be patient and try this, try that BUT I was exhausted. So when I asked for the epidural it was not primarily because of the pain, I just needed to press the pause button and have a rest. A good doula may have said to me - listen, just try the gas - an epidural will make the labour longer whereas if you keep things ticking along this baby will be out quicker. I KNEW that logically, but just needed someone to tell me that. So, a doula who was totally anti-drugs just would not have been a good, supportive person for me in that situation. If she'd said "oh, you've done so well, keep going, mind over matter, you can do it," - I wouldn't have listened. I HAD done well, but I needed something extra at that point.

As for lactation consultants/breastfeeding advice - again, there's a balance. The advice I got from the LC in hospital led me to spending 2.5 hours EVERY 3 hours for the first 2 weeks doing the breastfeeding, expressing, formula regime. So I got a half-hour break every three hours. I could have coped with that if there was light at the end of the tunnel and if DD had been improving on the breastfeeding but she wasn't. And the advice was mixed - oh, you have flat nipples so BF is going to be difficult but if you give formula you're doomed. So what are you meant to make of that? I think in hindsight I should have taken DP's advice which was "she's a bloody big baby, she's not going to starve and don't even worry about it until your milk's properly in, just keep trying until she gets it and stop hooking yourself up to machines."

But hindsight is a wonderful thing!

Erk. I guess you get 'personalities' in every industry, in every facet of life. This Mary Beth Harris needs to learn that preaching just to the converted wont actually 'help change the world' and also that the birth is not about her.

I think it takes a compassionate, knowledgeable and supporting woman to make a good doula and we're so blessed to have in you Kelly :D

This article just highlights the need to choose a good support team (OB, doula, midwife,whatever) and I hope it doesn't change the great trend towards doula's as I think they're fab! I also have a lot of support from my birth centre to have a doula and I think the fact that they're not 'scared off' by another knowledgeable person is a good sign.

I can't imagine walking out on a mum because she had an epidural.
To me that just screams of a doula who cannot keep her own stuff out of other people's births.
I've formed a connection with all the mum's I've worked with and the thought of walking out on any of them in labour - no matter what's happening - is just abhorrent to me. There is nothing she could choose that would make me entertain that for a second. Doulas are in it through thick and thin, I just can't fathom why you'd leave someone up the creek like that. :(
As far as pushing someone too far, that's such a fine line. It can be really hard to tell sometimes when a woman has really reached her limit or just needs more help. I think I'm getting better at this though!

Awwww Ren :) *blushing*

I guess you really have to do your homework when picking a doula and know what to ask, and check references! I have had clients call me, asking, 'I want a birth in hospital will you support me? The last doula would only support me if I had a homebirth.'

I think as a doula, in order to be a good one, you need to keep your clients happy, so you need to make sure their choices are respected and they are treated with dignity and care.

I agree like with what Ren said, you get complex personalities in any industry, gees you get rude wedding celebrants, Obs, midwives - and doulas too.

I think it's important to make sure your doula is clear about what you want, and the client is clear about the doulas beliefs about birth.

Doulas have grown in popularity from positive word of mouth, it's a booming job here in Australia and it wouldn't have done that with lots of dodgy doulas. So I think just make sure you really investigate your choices, don't just choose the first doula because you think she's nice but interview a few. You need to click above all, and so many people I call back who have left messages for me seem to make quick decisions - sometimes if I haven't called them back for 1-2 days they already have found someone! So people are making hasty decisions and I think this decision can't be made lightly!

I also think a doula should offer good resources to the client if she is worried about what the client is being told or what she understands, then allows the couple to make their decision. I can't sit back and watch stuff happen while the client looks on helplessly, like my birth centre client I posted about a few months back. I could not say nothing, it was disgusting. I don't often speak up but I feel an obligation to protect my client if need be. And most of my clients I attract want to be pushed past their personal limits to get that natural birth, but we always work out a 'red light'. It is a tough thing to learn! I have had one situation where I felt that I had to stop, the partner was freaking out majorly and demanding the epidural for his partner and not having met him before (he was too busy for visits) I didn't know this was him being a stresshead as he always was, and this was why she wanted me in the first place. She thanked me profusely after the birth for pushing her past that epidural she asked for. So you really need to know your client. But I would never walk out on one!!!