Partners   & Doulas
		“Asking your husband to be your sole guide through labour is like asking him to lead the way the on a climb of Mt. Everest. He may be smart and trustworthy, you may love him, but in the Himalayas you’d both be a lot better off with a Sherpa!”  Unknown

When it comes to pregnancy, birth, and parenting, today's father wants to share everything with his partner. He wants to be actively involved,  ease his partner’s labour pain, welcome his baby at the moment of birth and help care for his newborn at home. A labour doula can help a father experience this special time with confidence.

Studies show that when doulas are present at birth, women have shorter labours, fewer medical interventions, fewer cesareans and healthier babies. Recent evidence also suggests that when a doula provides labour support, women are more satisfied with their experience and the mother-infant interaction is enhanced as long as two months after the birth. With doula support, fathers tend to stay more involved with their partner rather than pull away in times of stress.

Today, a father's participation in birth preparation classes or his presence at prenatal visits and in the delivery suite is a familiar occurrence. Yet, we sometimes forget that the expectations of his role as a "labour coach" may be difficult to fulfill. Sometimes it is also culturally inappropriate for an expectant father to be so intimately involved in the process of labour and birth.

The father-to-be is supposed to, among other things, become familiar with the process and language of birth, understand medical procedures and hospital protocols and advocate for his partner in an unfamiliar environment and culture.

A doula can provide the information to help parents make appropriate decisions and facilitate communication between the labouring woman, her partner and medical care providers.

At times a father may not understand a woman’s instinctive behavior during childbirth and may react anxiously to what a doula knows to be the normal process of birth. 

He may witness his partner in pain and understandably become distressed. The doula can be reassuring and skillfully help the mother to cope with labour pain in her unique way. The father-to-be may need to accompany his partner during surgery should a cesarean become necessary. Not all fathers can realistically be expected to "coach" at this intense level.

Many fathers are eager to be involved during labour and birth. Others, no less loving or committed to their partner's well-being, find it difficult to navigate in uncharted waters. With a doula, a father can share in the birth at a level comfortable for him. The doulas skills and knowledge can help Dad, or other loved ones, to feel more relaxed. If the father wants to provide physical comfort such as back massage or help his partner stay focused during contractions, the doula can provide that guidance and make suggestions for what may work best.

A doula can actually bring a couple closer together. By assuring that the father's needs are met (food, drinks and emotional support) only then can he can give the mother his undivided attention. This is a stressful time for both mother and father. Fathers worry they are not doing enough or the right thing. A doula helps him to care for and support his partner by giving suggestions, providing encouragement or giving needed breaks during a long labour.

Physicians, midwives and nurses are responsible for monitoring labour, assessing the medical condition of the mother and baby and treating complications if  they arise. But childbirth is also an emotional and spiritual experience with long-term impact on a woman's personal well being. A doula is constantly aware that the mother and her partner will remember this experience throughout their lives. By “mothering the mother” during childbirth the doula supports the parents in having a positive and memorable birth experience. 

The benefits of doula care have been recognized worldwide. The Medical Leadership Council of Washington, D.C, the Society of Obstetricians and Gynaecologists of Canada and the World Health Organization are among the many healthcare organizations that value the benefits that doulas provide to women in labour.

The father's presence and loving support in childbirth is comforting and reassuring. The love he shares with the mother and his child, his need to nurture and protect his family are priceless gifts that only he can provide. With her partner and a doula at her birth, a mother can have the best of both worlds: her partner’s loving care and attention and the doula's expertise and knowledge.

©DONA 2001 

Three Articles of Dad's and Doulas
:: A Help for Fathers During the Labour and Birth of Their Child
:: Myths about Dads & Doulas
:: Hand Holding for Moms

	A Help for Fathers

A Help for Fathers During the Labour and Birth of Their Child
By Polly Perez
http://www.childbirth.org/CFE/dad.html

Our culture is one of the few that does not provide continuous supportive care for the labouring woman. Even though men are choosing to take active roles in the birth of their children, they are often put in a very uncomfortable situation. They attend childbirth and parenting classes and remain with their partners during the birth process, but often feel that they are expected to be the "labor authority" when they do not feel qualified for that role. No matter how good the childbirth education class was that he attended, his experience attending births is very limited, and, for the first time father, non-existent. Many fathers realize that they need reassurance, support, and guidance, also.

The father is in even a more precarious position if the mother has special needs. The mother who is labouring after a previous cesarean birth is emotionally vulnerable and may need constant support and encouragement about her ability to birth her baby vaginally. The father may be experiencing doubts, too. Fathers who must travel as part of their job, such as fisherman, off shore oil workers, and salesmen with territories out of town, often express concern about the possibility that their partner may not be able to reach them in time for them to be there to support her throughout the entire labour and birth experience. Parents who choose to involve their older children in the birth experience are often worried that it will be too great a burden for the father to support both mother and children. Parents expecting twins or triplets are both concerned about the differences that this may bring to their labour as well as their birth.

Professional labour assistants are able to bridge these gaps and provide that support and guidance for both the mother and father. Professional labour assistants may also be called doulas or monitrices. The word doula comes from the Greek; means "in service of" and in our culture denotes a person who provides continuous emotional and physical support for the labouring mother. The word monitrice comes from the French and means "to watch over attentively." Although their skill levels are different, the primary role of both of them is to provide continuous supportive care. Quite often people make the incorrect assumption that the labour assistant takes the place of the father and/or nurse. This is not true. The labour assistant is there to help the father help the mother, not replace him. The labour and delivery nurse has many duties other than supportive care, and is not able to be there continuously during labour and birth. She must leave when her shift is over as well as the fact that she is also responsible for charting, medication administration, maternal and fetal assessment, and administrative duties. The doula or monitrice is the perfect person to help bridge the gaps. Research studies by Klaus, Kennel, Hofmeyr, and others regarding doula care are showing a significant decrease in the request for epidural anesthesia, the use of forceps or vacuum extraction, length of labour, and cesarean section. The 1986 Klaus and Kennel study showed that, with standard hospital care, the cesarean rate was 17%, and when a doula was present continuously during labour, the cesarean rate was 7%. The 1991 study revealed that without a doula present the cesarean rate was 18%; with the presence of an observer, the rate was 13%, and with a doula present, the rate was 9%. The 1993 study also showed that the epidural rate was 27.9% with standard care and 14.7 with the addition of a doula.

When hiring a doula, fathers often comment that they want someone to be there to help take the pressure off them so that they can focus on being involved with their partner and the birth experience. They are also reassured knowing the doula will be present continuously if they must be absent at some time during the labour or birth. They now know that with the presence of the doula, that if their last birth ended in a cesarean, they have someone, in attendance, who will be able to help both of them over the emotional and physical hurdles of delivering vaginally after a previous cesarean.

The doula usually meets the mother and father prior to labour and is someone chosen by them, not just assigned to the case. She is someone known to both the mother and father, and can facilitate rapport with the hospital staff. In the book Special Women, one mother comments that she wanted someone that she chose to be with her, not someone she had never met before, and who might have to leave before she gave birth.

The mother with a multiple pregnancy relies on the doula to be the one person who is there just for her, as the nurse's tasks of assessing more than one baby may take up most of her time and concern. The doula also assists those families who want to involve their older children in the birth experience by her constant presence.

The doula or monitrice provides an initial consultation, prenatal, labour and birth support, and postnatal support. The initial consultation is usually 1-2 hours in length, and provides a time for the doula to develop a rapport with the father and mother to determine their needs and expectations. She is available for question and answer support via telephone, referrals to childbirth educators, pediatricians, lactation educators, lactation consultants, and postpartum doulas. In some cases, the doula may provide some of those services such as breastfeeding education, childbirth education, and postpartum doula support. During the labour, she is with the couple continuously and provides both physical and emotional support as well as acting as a liaison with the hospital staff and the primary care giver. During the immediate postpartum period, the doula encourages bonding with the infant and assists in initial breastfeeding. She also provides a follow-up visit either in the hospital or at the home.

	Myths about Dads & Doulas

Myths about Dads & Doulas
by Penny Simkin, P.T.

As one Dad put it... "We were Kim’s support team from the beginning and Marianne made sure I was involved but towards the end it was so hard that I needed her to take over. Marianne and I where holding Kim’s legs but at one point Marianne could see I was really scared and had the nurse come over and take my place. She read my mind. Also since Marianne was there to help it allowed me to help deliver my son. I’m so thankful that Marianne was there and that we made the decision to have a doula. I would recommend her to anyone. There truly is no other way to go."-Robb

:: Myth 1:
If a woman has her partner, the doula becomes redundant.

Reality: The doula may be the only person at the labour besides the partner who is there solely for the emotional well-being of the woman. The nurse, the doctor, the midwife have other priorities that compete with the emotional care of the woman: for example, breaks, shift changes, clinical responsibilities, office hours and hospital policies. The doula has few or no other priorities. She stays through shift changes, and until after the baby is born She is not just another stranger with the couple She has the woman's needs as her sole priority. In some cases, the couple will bring several other friends or family members into labour with them. Sometimes these people can be uncertain of how to help which leads to confusion and actually adds to the woman's stress. The doula can direct and coordinate the efforts of a group of people, giving them all some-thing useful to do, so they work as a team on the woman's behalf.

:: Myth 2 :
The doula "takes over", displacing the partner and interferes with their intimate experience.

Reality: The doula can actually bring the couple closer. By making sure that the partner's needs are met (food, drink, occasional back rubs, and reassurance), the woman and partner can work more closely together. The doula allows for the partner to participate at his own comfort level. Some partners prefer to be there only to witness the birth of their child and to share this experience with the woman they love. They may not want to play an active role and do not want to be responsible for the woman's comfort and emotional security. The doula can fill in and allow the partner to participate as he wishes, without leaving the woman's needs unmet. When the partner chooses to be the major source of emotional support, the doula can supplement his or her efforts by running errands, making suggestions for comfort measures, and offering words of reassurance and comfort. During a long tiring labour, she can give the partner a break for a brief rest or change of scene. While the doula probably knows more than the partner about birth, hospitals, and maternity care, the partner knows more about the woman's personality, likes and dislikes, and needs. Moreover, he loves the woman more than anyone else there. The combined contributions of partner and doula, along with a competent, considerate and caring staff gives the woman the best chance of an optimal outcome.

:: Myth 3:
The doula has her own beliefs about how the birth should go, and imposes it on the woman or couple.

Reality: The doula's true agenda is to help ensure that the woman's or couple's agenda is acknowledged and followed as much as possible. If the doula is thoroughly familiar with the couple's wishes and their birth plan, she may actually think more about it than the couple, especially when labour is intense and things are happening rapidly. The doula can remind the staff or the couple of some items on the birth plan that are forgotten, but which later might be important. Sometimes if a birth plan is not followed, the couple later look back with regret or disappointment. The doula helps with decision-making by asking questions that will ensure that the right information is given to the woman or couple so that they can make an informed decision. She may also suggest alternatives for the couple to consider. She does not, however, make decisions for the couple. 

In summary, the doula helps make the birth experience to be as rewarding and satisfying as possible. As one father said, "I heaved a big sigh of relief when she (the doula) walked in. I hadn't realized how much pressure I had been feeling. She not only calmed my wife, she calmed me down."

Penny Simkin, PT, is a physical therapist who has specialized in childbirth education since 1968. Among her books are Pregnancy, Childbirth and the Newborn: The Complete Guide, now in its third edition, The Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth, Episiotomy and the Second Stage of Labour, and most recently,The Labor Progress Handbook: Primary Interventions to Prevent and Treat Dystocia, with Ruth Ancheta. She has written chapters for three major medical textbooks, and a series of materials on pain medications and comfort measures for childbirth has recently been published by Childbirth Graphics. 

Currently, Ms. Simkin serves on several boards of consultants and editorial boards, including the journal, Birth: Issues in Perinatal Care; the International Childbirth Education Association; and the Seattle Midwifery School, where she also teaches. She is a founder of the Pacific Association for Labor Support (PALS), Doulas of North America (DONA), and trains doulas and doula trainers. Her practice consists of childbirth education, birth counseling, and labour support, combined with a busy schedule of conferences and workshops.

Copyright 1999 Penny Simkin

	Hand Holding for Moms

Hand holding for moms 
One father's ode to his doula -- the woman who remembered everything he forgot in Lamaze class.

By David Brauer 
From  www.salon.com

Dec. 7, 1999 
My wife, Sarah, crumpled the newspaper in exasperation. I perked up; this usually portends an interesting breakfast.

The object of her scorn was a column on the latest dust-up about drugs during childbirth. Once again, the debate was framed as a battle of ridiculous extremes: The no-drug mothers -- smug masochists who use birth as the ultimate extreme sport -- face off against narcotized moms who are weak, shallow stoners. "You either suffer or take massive loads of drugs," she said sarcastically. "No one is talking about what mothers really need -- which is support, so you may not have to do either."

Sarah is no ideologue. Two years ago, before our son Ian was born, she filled out a form in Lamaze class that asked her to rank the likelihood that she would need drugs during childbirth. She had to pick a level on a scale from 1 (roughing it) to 10 (Janis Joplin). She chose a 7. This was higher than I'd expected, but even a first-time father knows not to debate such things. When the time came, though, she needed no drugs at all -- thanks to the help of a doula, a professional labour coach.

If you've never heard of a doula, don't worry. Experienced birth attendants have been around since the beginning of humanity, but the term -- Greek for "trusted servant" -- dates back only to 1992, when a Seattle childbirth educator decided the position needed better branding.

Today, fathers are allowed in the delivery room and midwives sometimes elbow out doctors. Doulas fill a remaining gap: They serve as an experienced peer focused solely on the mother's physical, emotional and psychological needs. Doctors or midwives must split their time worrying about the baby's delivery; nurses typically shuttle among several births. Dads, of course, are riveted on their partners, but we're so deeply involved we can't be always be counted on for levelheaded decision making -- and besides, even we earnest Lamaze graduates have little experience in knowing what to do when dilation comes.

While doulas aren't medical professionals, their effectiveness has been documented by medical institutions. Allina Health Systems, a Minneapolis-based HMO and hospital network, did a 1996 "meta-analysis" of six clinical trials. The results showed a 50 percent reduction in Cesareans among mothers who used doulas, a 25 percent decrease in the length of labour and a 30 percent drop in the use of pain medication. When Allina did its own trial, the results were even more striking: Mothers assigned to doulas had 64 percent fewer Cesareans, 38 percent fewer epidurals and a 27 percent reduction in labour duration.

Even studies that showed no reduction in C-sections -- such as one done by California-based HMO Kaiser Permanente -- found that the use of doulas provided emotional benefits to mothers. Women accompanied by doulas are significantly more likely to cope well with labour, rate the birth experience as good and say that enduring labour improved their feeling of self-worth.

"If a doula were a drug, it would be unethical not to use it," says Dr. John H. Kennell, a pediatrician at Cleveland's Case Western Reserve and a father of the modern doula movement.

Yet despite its successes, the "doula movement" remains largely word-of-mouth -- which is how Sarah and I found out about it. A few years ago, I hosted a radio show. As the lone liberal on a conservative AM talk station, I'd use nonpolitical topics as a way to create space between caller insults. While Sarah was pregnant, my conversation naturally gravitated to the joys and fears of impending fatherhood.

Midway through the pregnancy, Doug, one of my regular callers, phoned after a show. His wife, Maureen, was a doula and wanted to offer her services. The cost was $300 for a couple of pre-delivery meetings, attendance at the birth and postpartum follow-up. (I later found out that doulas typically charge between $200 and $600, depending on region and extent of consultation.) I was suspicious, but Doug had proven himself to be one of my more thoughtful intellectual combatants, so I figured it couldn't hurt to meet Maureen. If it got weird, at least I'd have a good anecdote for a slow morning.

A suburban matron soon turned up on our doorstep, looking as proper and beatific as a door-knocking Jehovah's Witness. In truth, Maureen was an evangelical Christian -- a not-uncommon trait among doulas. The profession sports a liberal-conservative coalition rivaling WTO protesters: The God Squad is equally matched by the New Agers; both share a belief that birth is a natural and spiritual thing.

Since Sarah and I are confirmed secular humanists, my first reaction was, "Uh-oh." It would've been the same had an earth mother flounced in. But Maureen quickly won our trust. She focused on what we wanted out of the birth and asked us to be blunt about what we didn't want.

"Well, I said, "we don't want to be evangelized."

"Fine," she responded, "I won't." And she didn't.

Instead, she earned her description as a "servant" by passing on a ton of information about labour and delivery and running through various scenarios -- including the use of drugs during delivery. Some doulas, I'm sure, can let a subtle anti-drug bias creep in, but Sarah and I never felt that from Maureen.

Over the course of our pre-delivery sessions, we built up trust in Maureen, leading us to ask the sorts of questions we might not have been comfortable throwing out in a group class. It became easier to talk about fears -- including mine. I could admit my absolute lack of confidence, talking through each of my panic scenarios like a paranoid to a shrink.

Some couples worry that Dad will be upstaged by the doula on delivery day -- a reasonable fear. I tell prospective Dads that a few hundred bucks is a small price to pay for Knucklehead Insurance. Allowing fathers in the delivery room is a wonderful and well-intentioned gesture, but most of us are rookies as labour coaches, and it's ridiculous to have a rookie in charge of anything, much less his gravid wife's comfort.

"It's almost unreasonable the pressure we put on fathers," says Kennell. "I work with med students who have been training for a year, and when they go into hospital divisions for the first time, it's very common for them to feel faint. [Doulas] are a great psychological benefit to mothers, but also to fathers."

When Sarah went into labour, we found ourselves in a situation Maureen had warned us might occur: She was tied up at another, very difficult birth. She would have to send her backup.

Soon after we made it to the hospital, Allison, a severe Australian, arrived. The three of us had no bond outside of the fact that we all knew Maureen. The first hour didn't go well for me. Fortunately, it went well for Sarah. Allison locked on to Sarah like a lamprey to a rock. She was so competent and assured that I became nothing more than a marveling spectator. Sure, I'd learned about the birthing ball, breathing exercises and the soothing effects of the seated shower, but who knew when the time was right for each? Allison did.

While I wasn't interested in wresting command of the pain-relief detail, I also wasn't doing the most that I could do. I vividly remember standing behind Sarah, watching Allison work, and realizing that I'd drifted out of my wife's sight because of some imaginary inadequacy I felt in comparison to the doula, rather than concentrating on what the hell was happening with my wife.

But no one was telling me to be passive. I gathered my wits and decided to assert myself ever so gently. I moved back in front of Sarah, essentially sharing space with Allison. I started to ask Sarah my own questions when my instinct moved me, cracked a pallid joke or two and basically resumed being myself. This was met with no resistance; Allison was fierce but not a control freak.

With us, at least. There was one charged moment. A nurse had left Sarah hooked to a baby heart monitor. After several minutes, Sarah whimpered, "My belly's cold." I probably would have waited until the nurse returned, assuming that such discomfort was the price of vital information.

Allison snorted. "I'm going to get someone," she said, and stomped out of the birthing room.

Soon an apologetic nurse appeared; she explained that she'd been busy and had forgotten to unhook the monitor.

Some medical professionals resent having to deal with another party in the delivery room, though our OB and nurses apparently did not. Even the nurse who made the error sought us out after the birth to tell us how neat it was to work with the doula. I'm sure it's a relief for professionals working with us amateurs to have a seasoned intermediary to go through. Doulas themselves insist that they defer to the clinicians.

"Doulas say that their place is at the patient's head, not in the physician's way," explains Bonnie Blake, vice president of operations for two Allina hospitals.

That's how it was during the late stages of Ian's birth. Sarah experienced excruciating back labour, but she didn't ask for an epidural. Allison stood behind her head, offering steady suggestions: how to turn, how to breathe -- simple suggestions that I would have been grasping to recall, had a doula not been there. I sat next to Sarah, held her hands, gazed into her eyes and offered reassurance. Meanwhile, the OB and the nurses worked undisturbed. After six and a half hours of labour, Sarah delivered our perfect baby son.

Our doula did not prove herself to be some sort of human ibuprofen, able to miraculously mask the pain. "Childbirth didn't feel like people said it would feel -- it hurt a lot more," Sarah recalls. "But fear makes pain worse. Maybe my pain wasn't any less, but I wasn't afraid. I would have been terrified if Allison hadn't been there to tell me this was normal."

Now that we've become doula acolytes, I'd like to know why health plans are so timid about promoting them. Forget, for a moment, about the emotional advantages. Even in the bloodless financial world of the modern HMO, doulas make sense. Each bypassed epidural saves about $150; a forgone C-section saves around $3,900. If one woman in 10 avoids a Cesarean, the money saved could pay for doulas for all. This, folks, is health maintenance.

Yet even Allina, which documented the benefits of doulas in its own studies, offers a mere $150 toward the expense of hiring a doula, and this incentive is available at only two of its 15 hospitals.

Allina, says Blake, wants to slowly increase the use of doulas, gradually making sure the benefits shown in the 1996 study hold. Still, it's no accident that its hospitals with doula programs also lack nurses' unions. Two Allina officials told me that the nurses' union fears that the doula program is a backdoor attempt to reduce the number of nurses on duty.
Blake insists Allina isn't looking to replace nurses with doulas. She predicts that resistance will drop as more nurses work with patient-provided doulas -- and don't lose their positions because of it. Physicians don't see doulas as a direct threat to their profession, but some still need to see the advantages of doulas for themselves.

Union nurses aren't the only one who distrust Big Medicine. Doulas are thought of as cool and sort of alternative when patients seek them out, as we did, but Blake suggests that mothers might find it more difficult to bond with a labour coach if institutions are the promoters. "We prefer to be a less paternal organization," she says.

I don't know. It is possible that health-care costs might rise in covering the heart attacks people would experience when offered cheap, innovative, human support -- but I say let's take that risk.

Two months ago, Sarah discovered she was pregnant again. Our baby is due in June. Of course, we're going the doula route again, reimbursement or not. This time, Maureen promises us she'll be there.