Encounter with a doula: is the system failing new mothers?

I would like to thank Stefanie Antunes for her response on behalf of
Doulas of North America (DONA) International. Although all responses are
appreciated, it is not clear what article Ms Antunes is referring to in
her/DONA’s rebuttal. She seems to exclusively refer to quotes from a BBC
article,[1] written by a BBC journalist and not myself. For example,
Louise Silverton, Deputy General Secretary of the Royal College of
Midwives, did not make any claims in my article but was interviewed for
the same BBC article.

The original BMJ article was a ‘personal view’ meant to inform my
colleagues and stimulate some debate.[2] It started with a case report of
an encounter with a doula, discussed a minor (and quickly resolved)
communication problem that occurred and went on to discuss the wider
implications of a doula service. I believe the crux of my article was
apparent in its title “...is the system failing new mothers,” that perhaps
a doula service is necessary due to the potential failings of society and
health services. It was never a blind criticism of doulas, and to repeat
from a previous response, I feel that “Doulas obviously make a great
difference to some women, lifting the childbirth experience, and it is in
no one’s interest to demean that role.”

I will however endeavour to answer some of the issues alluded to by
Ms Antunes and point out areas that do not refer to the original article.
I am grateful for the opportunity to do so.

1. The importance of emotional support for mothers (and partners)
before, during and after birth has never been questioned. The benefits are
obvious and I wonder if they require research to provide evidence. In a
world where we are trying to avoid unnecessary medicalisation, it seems a
shame to then go and attempt to study the most basic of human emotions in
an effort to support the obviously beneficial with ‘relative risk
reductions’ etc.

2. I understand that many doulas are members of organisations such as
Doula UK and DONA in the USA and the often voluntary activities of
individuals within these organisations are admirable. However, many doulas
are not members and as Jean Birtle of Doula UK says, in the same BBC
article,[1] “This is a problem. The bottom line is that you do not
interfere in any way, but unfortunately there are women coming into this
field who have very little training and no real code of ethics. It is not
her job to challenge the doctors or influence the mother one way or
another, but to support her…” Nevertheless membership is voluntary,
unregulated as Ms Antunes points out, and there is no national or
internationally recognised certification or body where complaints can be
made and recourse sought. We live in a world where most parents would not
consider sending their children to schools where staff had not had
criminal record checks for example, nor would they employ an unregulated
plumber. However, there are no background criminal record checks performed
for the majority of doulas, who spend time with people at a vulnerable
stage of their lives. Whether checks are required is beyond the scope of
this discussion but I find this dichotomy in thinking interesting. Whether
for profit or not, and regardless of earning potential, doula services are
generally not free and so should be scrutinised as any other premium
health-related service.

3. Louise Silverton, Deputy General Secretary of the Royal College of
Midwives had no input in to the original article and made no claims in it,
but did so in the BBC article.[1] She also said, “It is important that at
local level midwives, doctors and doulas establish clear relationships and
understandings about their respective roles. The woman and her baby is the
focus of midwives' care, and whoever the woman chooses as her birth
partner should work in harmony with midwives to ensure a safe and
comfortable environment for the woman…Let me be clear about one thing,
doulas should not interfere in any way in clinical decision making.”
Nobody is denying the pressures faced by the NHS and its employees are
often the first to notice and then criticise its short comings in an
effort to improve matters.

4. I did write, “Both the mother and father were confident and
articulate, so I couldn't help but wonder why they needed to pay for
support” but unfortunately this is taken out of context as the quote seems
to be taken from the BBC article and not the BMJ. The full BMJ article
goes on to say: “As healthcare professionals we forget how much of an
unknown the body’s processes are to the general public, that much of what
we take for granted is a complete mystery to even the most confident and
articulate lay people. The processes of child birth are new and anxiety
provoking experiences, and what people fear most is the unknown. Combined
with the often time pressured hospital environment and need for quick
decisions, this takes control away from the individual. A lack of
continuity in carers does not allow parents to develop trust in
clinicians, as they find themselves having to start new relationships
every 12 hours, diminishing the quality of communication. People seek some
continuity in their support in stressful situations; perhaps doulas fill a
gap in this market.[2]” I made no assumption that confident and articulate
people cannot benefit from support and DONA should not make assumptions
without reading the full article. I think we can all agree that there are
circumstances or ‘voids’ where we cannot deliver the level of care that we
would like to and birth assistance be it from families or doulas may fill
this gap.

5. Obstetric care is expensive to provide and is labour intensive.
However, health care systems are committed to providing high quality,
tightly regulated, care despite the cost in a truly evidence based manner.
Is it in the doulas to remit to reduce hospital expenditure? I must admit
that it is an admirable aim but reduced cost does not necessarily
correspond with a reduction in ‘unnecessary’ interventions.

6. Being a North American group, DONA and its members may not be
aware of the workings of the NHS. It is a nationalised health service,
offering free care to all at the point of service, rich or poor,
irrespective of where you live. It even offers emergency care free to
those from abroad. It covers all costs from conception to post delivery
and includes additional benefits for pregnant mothers such as free dental
and eye care as well as free prescription drugs. NHS doctors, nurses, and
midwives are government employees who earn the same regardless of the
number of ‘interventions’ they perform, be they blood tests, scans,
instrumentals, operations or epidurals. There is no financial transaction
between service users and doctors or hospitals and although women in
labour are not unwell they do benefit from the patient-doctor
relationship; primum non nocere. I would like to make clear that no
operation, Caesarean section, epidural, or instrumental delivery is ever
‘routine’, they may appear easy or routine to the untrained observer
because we are trained to do them in a calm manner but don’t be fooled.
Each ‘intervention’ has its own benefits and complications and every time
a doctor or midwife is involved with an ‘intervention’ they do so because
they feel that in their trained professional experience that it is
necessary for the benefit of the mother or baby. There is no financial
incentive. They also do so knowing that all of their actions are under
close scrutiny and they are potentially legally liable for complications.
Interventions do not make doctors’ lives easier. Interventions are carried
out only with the informed consent of the mother.

7. Again, I did not state: “that the kind of women who are very
determined to achieve a ‘normal’ birth are more likely to hire a doula
than those who do not see medicalised childbirth as a problem”; this too
was from the BBC report.[1] However this does introduce some interesting
concepts: What is a ‘normal’ pregnancy or birth? Where should it happen
and what services are involved? When in a pregnancy does the acceptability
of medicalisation change? The birth is part of the pregnancy that often
comes after months of medical and midwifery input with scans, clinics and
blood tests. This pre-natal care and not technological advances is what
has made childbirth so safe in the ‘Western’ world and what is sadly
lacking in some developing countries where peri-natal deaths are so high.
It is of course the mother’s right to choose how her pregnancy, labour and
birth proceeds but if we are happy to accept ‘intervention’ in the
prenatal stages, why is there such a paradigm shift later on?

8. Ms Antunes, women are not failures if they have epidurals,
instrumentals, or Caesarean sections – again I am not sure whose quote
this is. It may be that they feel that way because of prenatal pressures
to achieve a ‘normal’ delivery. Surely more focus should be placed on
outcomes such as the mothers health and the baby’s health and less so on
the methods employed to achieve these, bearing in mind that interventions
have medical indications and are conducted only after informed consent
from the mother.

9. The only absolute indication for an epidural is maternal request
and one of the few absolute contraindications is maternal refusal. With
respect, it is the performing doctor’s responsibility to discuss the risks
of a procedure not the doulas. No procedure should take place without
informed consent including discussions of risks (short- and long-term) vs
benefits, and a doctor is legally obliged to do this and cover any issues
such as capacity. Gaining medical consent is an important medical
procedure and as DONA makes clear, doulas are not medically skilled and do
not give medical advice, so it would seem clear that if a mother requests
an epidural or an intervention is deemed medically indicated, then further
discussion about the epidural or intervention is outside of the doulas
remit. If it is felt that an inadequate explanation has been given or
poorly informed consent taken, then this should be raised with the medical
team and mothers and families should be empowered to do so.

10. It is also worth touching on evidence and statistics at this
point. DONA states: “An abundance of research has been carried out
regarding the benefits of doula support during labor and birth and the
results consistently show better maternal outcomes, reduced intervention
rates, greater satisfaction and better neonatal outcomes, regardless of
women’s choice for pain relief”, “Doulas provide access to evidence-based
information so their clients can make the decisions that are right for
them”, and “When parents express confusion or have questions beyond what
their care provider has offered, the doula helps them access additional
information and validate its basis in evidence to aid in their decision
making.” However, it then says: “The individual doula’s focus is not about
statistics or changing outcomes.” This is very confusing as statistics are
integral to evidence based medicine and it has already suggested how
doulas can change outcomes but these outcomes are not specified? A
Cochrane review of ‘Continuous support for women during childbirth’, by
Hodnett et al in 2007,[3] showed that there was a relative risk reduction
(RRR) in maternal dissatisfaction by 27%. It also demonstrated RRRs in
analgesia, instrumentals and Caesarean sections but the confidence
intervals all approached 1.0 closely, and p values are not clear, so the
statistical significance is also not clear. The meta-analysis however
showed no difference in neonatal outcome (APGAR score or incidence of
admission to NICU), incidence of oxytocin labour augmentation and severe
post-labour maternal pain. It is accepted that statistical significance
does not necessarily equate to clinical significance, as even one happier
mother is important, but DONA is not clear whether doulas are evidence
based or not. It may be unbalanced for DONA to refer to evidence of
improved neonatal ‘outcomes’ without specifying the specific outcomes and
mentioning that there is evidence suggesting no difference. Validation of
evidence requires an understanding of statistics and research methodology.
Relative risk changes are difficult to understand without knowledge of the
actual risks and the denominator, especially if the following is true.

11. DONA states in its response: “The hormones of labour cause a
natural shift in awareness, which can greatly impede a woman’s logical and
objective judgment. Partners may be insecure in their ability to fully
comprehend the risks and benefits of common procedures or to effectively
seek out this information during labour because of their strong emotional
involvement in the process. When parents express confusion or have
questions beyond what their care provider has offered, the doula helps
them access additional information and validate its basis in evidence to
aid in their decision making.” This statement is concerning. Is DONA
suggesting that women lack the capacity to make informed decisions in
labour? Drugs and pain may reduce capacity but I am not an authority on
the legalities and ethics of consent, and have a working knowledge. The
health system and medical professionals in the UK assume that a mother has
capacity to decide her own treatment unless there is clear and compelling
evidence to suggest otherwise. Even then, deciding that a mother lacks
capacity is a complex task with the burden of proof falling on the health
system. Women show an uncanny ability for calm in labour, to take in what
is explained to them. I would be interested to see evidence suggesting
lack of competence. Under UK law, no other person (including partners and
carers) can consent another adult for treatment or project their own
values to sway a decision. If a person were to lack capacity somehow, then
moves to gain additional information or validate its evidence basis are
not useful as they cannot be weighed up by the person. Managing people
with (presumed or actual) loss of competence requires great experience,
training, legal input, and is an ethical dilemma.

It is a shame that DONA International felt the need to offer a
rebuttal, and then not to the original article but to a media generated
representation. An evidence basis is not everything and statistical
significance is not always important. The media see it fit to
sensationally report articles in an effort to generate news, pitting
doctors against the public and other carers. The original article was by
no means anti-doula but it did ask questions. To be a professional means
to question others, to question one’s self and to be open to questioning
by others.

To repeat from a previous response, “There is a gap in the market and
traditional health services cannot fill this alone. We all have an
important role to play in the care of mothers and must work together;
defining our roles clearly does not detract from this. Ultimately, the
mother and baby's health is paramount, as is the mother's happiness and
free, informed, choice.”

Dr Abhijoy Chakladar

[1] Murphy C. Doulas: holding hands or stepping on toes? BBC News
Online, 2 December 2009. http://news.bbc.co.uk/1/hi/health/8389306.stm.

[2] Chakladar A. Encounter with a doula: is the system failing new
mothers? BMJ. 2009;339:b5112

[3] Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for
women during childbirth. Cochrane Database Syst Rev. 2007;(3):CD003766.
DOI: 10.1002/14651858.CD003766.pub2

Competing interests:
AC is the author of the original article.