Why Doulas Make it Better

More choice. Fewer Cesarean Sections. Higher satisfaction.

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Doulas are part of a wave of change that is taking place as we try to recapture the birthing process as a natural, physiological process, beautiful and daunting, and entirely possible most of the time with little or no medical intervention.

Birth is a beautifully designed system that 85% of the time needs little medical intervention to go well.  Doulas help women understand and make choices during labor and delivery in accordance with their wishes and with this principle in mind.  Current evidence underscores the powerful positive impact of having a doula in the delivery room (whether in a hospital, birthing center, or home).

Over the past 75 years,  birth in the U.S. has become a highly medicalized process that usually takes place in a hospital – the place where sick and broken people go to get cured or repaired.  Birthing mothers are neither sick nor broken, and they generally seek the safety of a hospital just in case something goes sideways, not because they need heavy-handed medical treatment. 

More and more, birthing mothers, these days push back against outdated and unnecessary hospital protocol and seek a more natural and unhurried birthing experience.  Birthing mothers who have a doula in attendance are far less likely to have a Cesarean Section, have fewer interventions in general, and report significantly higher satisfaction with their experience overall.  In short, doulas make it better.

Astonishingly, today over 30% of American women have Cesarean Sections (major abdominal surgery) rather than vaginal deliveries, and as many as half of these Cesarean Sections likely were not medically necessary. The World Health Organization estimates that 10-15% of births need to result in Cesarean Section, and this statistic includes women from all over the world, many of whom do not have adequate prenatal care.  Hence, one would expect the number to be lower than 15% in a developed country like the U.S.  But for a host of reasons, this is not the case. 

Here’s an uncomfortable insight into part of the problem:  Major surgery to accomplish birth, while fast, relatively easy, and far more lucrative for providers, leaves birthing mothers with much longer recovery periods, more pain, and increased vulnerability to post-partum depression, breast-feeding problems, and repeat Cesarean Sections.  Emily Oster, the author of Expecting Better and a Brown University economics professor, believes that the U.S. Cesarean Section rate would fall dramatically if providers were paid just as much for vaginal deliveries.  It makes you wonder.

Aside from Cesarean Sections, there are other interventions that happen far more often in the U.S. than elsewhere.  Labor induction is currently the most prominent and troubling one. The American College of Obstetrics and Gynecology posits that healthy women at 39 weeks of gestation can and should be offered induction and even suggests that overall outcomes are better this way because certain risks are eliminated by inducing at this point.  The studies around this issue appear to focus exclusively on narrow “healthy mom/healthy baby” outcomes, which don’t differ dramatically either way.  This approach fails to take into account how much more difficult and uncomfortable women find induction to be, especially if they are trying to have an unmedicated birth. 

Many inductions go on for days, with the birthing couple stuck in the hospital and unable to get much rest, the birthing mom tethered to machines and often not allowed to eat anything.  As the medical team ramps up the Pitocin to get contractions going, the pain often becomes intolerable early in labor, leading to an epidural, a Foley catheter, increased dosage of Pitocin to maintain a contraction pattern, inability to move or change positions easily with a numb lower body, and difficulty pushing effectively.  The memories that induced birthing mothers carry away from the experience often include a loss of control in the face of overwhelming pain, being defeated by exhaustion, losing the ability to make choices as the intervention path becomes a slippery slope of one thing after another, and the ever-looming threat of Cesarean Section as time drags on.  And a quarter or more of induced mothers will ultimately end their journey with an unwanted but apparently unavoidable Cesarean Section. 

The healthy mom/healthy baby metric completely overlooks these intangibles and their lasting effects and also the longer-term issues like increased vulnerability to postpartum depression or breastfeeding problems.  Birth doulas provide much needed support during inductions.  They are well-versed in the pros and cons of all of the various interventions and can be enormously helpful to the birthing mother and partner as they navigate and make choices.  In our experience, inductions with a doula are about half as likely to result in Cesarean Section as those without. 

Whether a birth is spontaneous or induced, birth doulas play a key role in terms of offering the birthing mother (and partner) information, emotional and physical support, and comfort measures as they try to experience birth the way they want to.  A birth doula provides continuous, informed reinforcement and encouragement to the birthing mother and helps preserve her ability to make decisions for herself, often in the face of pressure to accept interventions that she may or may not want.  Many hospitals now welcome the presence of doulas.  The nursing staff is generally the most open and appreciative.  Some doctors/midwives appear to feel that doulas undermine their authority, although doulas generally try very hard to be collegial and respectful.  We do, however, ask questions and help birthing mothers and their partners to ask questions and explore their options.  We empower the birthing person (and partner) by helping them to understand when they have the right to choose.  For a provider who approaches decisions about care in an authoritarian rather than preference-driven and collaborative way, the presence of a doula can sometimes be frustrating.  Even so, the results speak for themselves.  Birthing mothers who have doulas with them have better experiences and outcomes.

  Birth is an amazing and wonderful but also a challenging rite of passage for the mother, partner, and baby.  Each birthing mother should have the right to choose how she wishes to give birth and which interventions to accept and when, while also preserving her sense of safety and reassurance that emergencies can be dealt with effectively in a hospital if that is her wish.  She should be supported in a way that allows her to come through the process feeling empowered, safe, and sure.  Doulas strive to make this possible for each and every birthing woman.