By Mary Ann Hellinghausen
Illustration by Malcolm Garris/PhotoDisc
August 6, 1998

When Ana Draa arrives at a hospital to assist a laboring mother, the labor and delivery nurses are often curious about her big suitcase stuffed with therapy oils and hot packs, and her big, green birthing ball.

They are the tools of a doula, a person who helps women in labor by providing physical comfort and emotional support to make the experience as positive as possible. While doulas are present at only 1 percent of the births in the United States, some hospitals are beginning to keep doulas on staff in light of studies demonstrating their cost-cutting benefits.

Filling a gap

A doula (a term derived from an ancient Greek word meaning a servant) usually is hired by a pregnant woman to help her through the labor process. Doulas assist pregnant women by helping with breathing patterns, massage, and hot packs or ice packs.

Doulas normally have no clinical training, and, in fact, those certified by Doulas of North America (DONA) promise not to use any clinical skills. "The doula isn’t taking the place of the clinical caregiver or the partner, but is filling a gap and making the birth team whole,’’ said DONA spokesperson Lesley James.

DONA-certified doulas must attend a three-day course that covers the anatomy and process of labor and techniques for supporting women in labor, according to DONA. Doulas must also have good evaluations from clients, nurses, physicians, and midwives, and document three births at which they have provided continuous support.

Doulas usually charge $300 to $500, and insurance coverage for doula services varies widely. Some doulas have contracts with managed care companies, said Polly Perez, RN, a Houston nurse who trains doulas and has written three books on the subject. Sometimes managed care will pay for a doula if the mother agrees not to have an epidural, said John Kennell, MD, a professor of pediatrics at Rainbow Babies and Children’s Hospital in Cleveland.

What the research says

Research has shown a 50 percent decrease in cesareans, a 60 percent decrease in epidurals, a 40 percent decrease in the use of Pitocin, and a 25 percent decrease in the length of labor when a doula is present, according to DONA.

In May, University of Texas researchers released a study on the effects of doulas, reporting that women who had doulas with them during labor were more sensitive, loving, and responsive to their infants two months later. The researchers had randomly assigned 104 women who were delivering their first babies to three groups: women with a doula, women who received narcotic pain medication on request, and women who had epidurals. The families that had doulas scored highest on the Bayle Scales of Child Development, with an average score of 5.5 on a scale of 1 to 7; families in the other groups scored about 4.5.

Working with doulas

The American College of Nurse-Midwives has no official position on doulas, but Executive Director Deanne Williams, RN, a nurse-midwife, said the support doulas offer is welcome. "The most important thing is that a woman is not left alone during labor. It’s a sad commentary that we continually have to champion this cause.’’

If a nurse-midwife has a particularly busy practice, Williams said doulas can help provide physical and emotional support while the midwife concentrates on managing and assessing the labor process. The two jobs are complementary, she said.

Jeanene Winfiele, RN, nurse manager for labor and delivery at Houston’s Lyndon B. Johnson Hospital, worked with doulas at Jefferson Davis Hospital about 10 years ago. The doulas were funded at the county-owned hospital for a short time as part of a grant program, she said.

"They were a very good support system for patients who had no family there," Winfiele said. "The patients would usually dilate and progress much faster. I was very impressed.’’

Texas' Harris County Hospital District has since closed Jefferson Davis Hospital and opened LBJ, which provides care for many of the county’s indigent patients. Winfiele said doulas are uncommon at LBJ, but a new grant for a study on doulas will provide funding for them.

Draa, who has assisted in about 40 births in the Houston area, said many nurses have never heard of a doula and don’t always understand her role. "They just don’t know quite what to make of us at first,’’ she said. "I introduce myself immediately and make myself as useful to that nurse as possible. I do everything I can to endear myself to her.

"My experience is that most nurses care very deeply about their patients, but are shorthanded when assigned to more than one patient,’’ Draa said.

Perez said pregnant women’s partners need not fear that doulas will take over their role. "For most partners, no matter how well meaning they are, this is new territory,’’ Perez said. "They’ve never seen their wife in pain. Doulas can be more objective. We’re not there just for the mom, but for both of them.’’