The Doula Book How a Trained Labor Companion Can Help

You Have a Shorter, Easier, and Healthier Birth

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 CONCLUSION: A CHANCE TO ENHANCE THE
SAFETY, COMFORT, AND SATISFACTION OF THE ...
OUR RECOMMENDATIONS

Chapter 6 - Longer-Term Benefits of Doula Support

A SENSITIVE PERIOD
EFFECTS ON THE MOTHER AFTER THE DELIVERY
PARENT-INFANT BONDING

Chapter 7 - Birth with a Doula

A HOSPITAL BIRTH WITH A DOULA
A HOME BIRTH WITH A DOULA

Chapter 8 - A Father’s True Role

FATHERS AT DELIVERY
DOULAS AND FATHERS: TWO DIFFERENT ROLES
HOW FATHERS EXPERIENCE BIRTH
CAN A FATHER BE A DOULA?
HELPING A FATHER PARTICIPATE

Chapter 9 - A Female Relative or Close Friend Trained as a

Doula
STUDYING THE EFFECTS OF A LAY DOULA
A CYCLE OF CARING

Chapter 10 - Postpartum Care

LEAVING THE HOSPITAL
AT HOME
PRIMARY MATERNAL PREOCCUPATION
POSTPARTUM DEPRESSION
HELP AT HOME
GETTING STARTED WITH BREASTFEEDING
A DEVELOPMENTAL APPROACH TO LEARNING TO
LATCH ON
POSTPARTUM DOULA
APPENDIX A: - THE TRAINING OF A DOULA
APPENDIX B: - RELAXATION, VISUALIZATION, AND SELF-
HYPNOSIS EXERCISES FOR ...
APPENDIX C: - CHARACTERISTICS OF RANDOMIZED
CLINICAL TRIALS OF LABOR SUPPORT
APPENDIX D: - RESOURCES
NOTES
INDEX
ABOUT THE AUTHORS
Copyright Page
 ALSO BY THESE AUTHORS
Bonding: Building the Foundations of Secure Attachment
and Independence

ALSO BY MARSHALL AND PHYLLIS KLAUS

Your Amazing Newborn
We dedicate this book to all the sensitive and caring women
who have provided continuous support during labor for the
mothers in our studies. They have helped us in
immeasurable ways to evaluate, describe, and begin to
understand the power of their presence. We also dedicate
this book to all the doulas in the future who will enable
mothers and their partners to have a less complicated and
more rewarding birth with long-term benefits.
Doula is a Greek word whose definition has come to mean a
woman who helps other women. The word has further
evolved to mean a woman experienced in childbirth who
provides continuous physical, emotional, and informational
support to the mother before, during, and after childbirth.
 ACKNOWLEDGMENTS FOR THIRD EDITION

Our understanding of the needs of mothers and their

partners during labor developed during our systematic
studies and clinical experience over the past thirty-six
years. Insights also came from discussions with doulas and
close colleagues Steven Robertson, Susan McGrath,
Roberto Sosa, Manuel de Carvallho, Clark Hinkley, Penny
Simkin, Nadia Stein, Roberta O’Bell, Susan Landry,
Kenneth Moise, Majorie Greenfield, Kathy Scott, Charles
Mahan, Michael Klein, Debra Pascali-Bonaro, and the late
Moisies Paciornik. We also appreciate the thoughtful and
significant work of Carol Sakala and Maureen Corry.We
thank Della Campbell and Michelle Falk for their important
work, which is included in Chapter 9. The excellent book
and discussions with Sarah Buckley inspired us.
We also thank the medical students, and especially
Wendy Freed, who more than three decades ago sparked
our interest in exploring the needs of women during labor
through observations she made when she stayed with ten
mothers during labor as part of another study. Apparently
benefiting from her supportive presence, these mothers all
had a remarkably short labor and a complication-free birth.
These observations were a critical stimulus to our
exploration of the effects of a doula.
We appreciate the major conceptual additions to this
book by Kerstin Uvnäs-Moberg and the Swedish midwives,
Ann-Marie Widström, Anna-Berit Ransjö-Arvidson, Eva
Nissen, Kyllike Christensson; and Wikbe Jonas, as well as
Beverley Chalmers, G. Justus Hofmeyr, Wendy-Lynne
Wolman, and their Johannesburg research colleagues; and
Christina Smillie with her new information about the latch-
on in breastfeeding.
 The perceptive comments of Laura and David Abada,
Susan and Bob Sholtes, Devi and David Borton, Kristin
Brooks and Glenn Meyer, Humm Berreyesa,Tracy Fengler,
and Frances Bachman were especially helpful.
We thank our secretary in Berkeley, Nancy Pino.We are
grateful for Peggy Kennell’s early contributions and her
strong, doulalike patience and support.
Finally, our heartfelt thanks to Merloyd Lawrence for her
continuing encouragement, sensitive understanding,
remarkable editing skills, and wise counsel.
 INTRODUCTION TO THIRD EDITION

In this revised edition we are highlighting the importance

of returning to natural birth. Unfortunately, in recent years
the pendulum has swung once again to a surgical or
interventionist approach to childbirth. One in three women
will have a cesarean section in this country this year. This
is an assault on women and infants. We are compelled to
present another way of birth that will prevent most of these
injurious interventions. Close to two-thirds of these
cesarean sections are unnecessary and preventable. But
sadly, these c-sections are often encouraged by giving
women the false idea that they should have the “choice” as
to whether their baby is born by a surgical or induced
method, or through the natural process of her own body.
We stress this concern in Chapter 5, and we illustrate how
increased inductions, cesarean sections, and epidurals used
have caused an increase in the morbidity and mortality of
baby and mother. We describe how the role of the normal
hormones of birth, which significantly reduce pain and
make birth much easier, is interrupted by the interventions
and thereby denied to the mother and baby. Inductions, c-
sections, and epidurals should be used only when medically
necessary, such as when either the mother or infant shows
signs of distress.
The studies we cite in this book of the birth outcomes for
over 16,000 women, with and without doula support, show
that continuous support from an experienced labor
companion can be dramatically beneficial. The use of a
doula can shorten labor by 2 to 3 hours and significantly
reduce complications and the use of cesarean sections. Also
there is a remarkable drop in the mother’s need for pain
medication. We are enthusiastic that the major rating
agency of obstetrics, the Cochrane Database, has
acknowledged through detailed meta-analysis the
importance of the doula as the most effective support for
women and their babies during labor.
In Chapter 4 there’s now more emphasis on hypnosis and
massage for pain reduction, and we detail how to help the
mother be actively prepared to use these and other pain
reducing methods rather than epidurals and opiates.
Chapter 9 discusses how a close female relative or friend
who functions as a doula after a few hours of training can
affect in a positive way a mother’s long-term view about
her baby and herself. This is especially advantageous for
women for whom the professional doula may not be
available or affordable or those who prefer to have the help
of their mothers or someone very close to them. The chosen
female relative or friend who has been trained along with
the mother-to-be can now offer more with the skills and up-
to-date information she has gained from this 4 hour
training from a professional experienced doula. Although
most birth centers and hospitals or clinics allow support
people and family members to accompany the mother, we
now know that a doula’s care is more than hand-holding.
She is more than a mere presence. A family or friend doula
needs some skills and information on how best to help the
woman work with her labor and reduce pain.
The sensitivity of the relationship has an enormous
influence on labor. If a support person feels inadequate, her
anxiety or insecurity can transfer to the mother and affect
her confidence. A number of women have said that they
could sense immediately if a nurse or caregiver who greets
them will be hurtful or helpful by their demeanor. It is easy
to make a mother feel judged or that she is not laboring
right or fast enough. Some women state that they give up
or lose their power after such comments such as “You don’t
have to be a martyr. We can get you an epidural”; or to a
woman whose labor has slowed down even though she is
doing fine medically a caregiver said “You’re still here! “
Other harmful comments such as “You’ll want an epidural,
just wait and see” indicate a lack of trust in the mother and
undermine her confidence or control.
Current knowledge about mirror neurons, a subtle type
of brain to brain communication discovered by Italian
researchers, gives us a powerful indication that especially
in vulnerable times we can in some way pick up the
intention of another person. This could be a survival
instinct. We have noticed that a woman left alone with a
very nervous partner could easily lose her confidence.
Stress hormones can rise. A woman’s whole labor and
delivery atmosphere requires an attitude of warmth,
kindness, confidence, and trust as well as continuous
support. How a woman is treated in her first birth can
affect the rest of her reproductive life.
What is important for any doula (friend, relative, or
professional), is her ability to give consistent and
continuous support throughout labor. Only with continuous
support is there a significant improvement in the results
compared to routine care alone. In Chapter 5 we describe a
meta-analysis comparing intermittent with continuous care
which reveals that intermittent care has no effects
statistically different from those of routine care, while
continuous care had significantly valuable results.
In the final chapter and Appendix A we show that a
doula’s role must include awareness of the needs of the
new mother right after birth, being able to have a long time
with her baby, skin to skin as she wishes, but also helped to
be comfortable and have her physical and emotional
concerns met.. If the infant is not affected by anesthesia,
the mother can be helped to see the baby’s natural
responses, and become more comfortable with
breastfeeding.With a shorter and easier labor, a traumatic
birth can be avoided and the mother can be united with her
baby from the start.
 1

The Need for Support in Labor

Continuous support from a doula during

labor provides physical and emotional
benefits for mothers and health bonuses
for their babies. With less medical
interventions, fewer complications, and
shorter hospital stays, there may be
financial savings as well.
HARVARD HEALTH LETTER

Throughout human history women have always helped

women give birth. Virtually all non-industrialized, hunter-
gathering and agricultural societies offered, and still offer,
mothers the continuous support of other women during
labor and delivery. As childbirth moved from home to
hospital, however, this vital ingredient in childbirth began
to disappear. While efforts to involve fathers and introduce
other humane practices into hospital births have done
much to improve this situation, an important link remains
missing. Although the introduction of fathers into the birth
room brought the couple together at this important time,
this practice tended to reduce the sensitive and
experienced care of the obstetric nurse during labor.
Childbirth tended to become lonelier and more
psychologically stressful for parents.
 More recently, concerns have been raised about rising
rates of cesarean sections and the highly technological and
impersonal nature of childbirth. These trends have led us,
together with colleagues, to study the effects of restoring
the role of women helpers in the childbirth experience. Our
research has now demonstrated that continuous support
from an experienced labor companion can be dramatically
beneficial. As we will show in the later chapters of this
book, in studies of over 16,000 women comparing
outcomes with and without such support, we have seen a
major reduction in the length of labor, a greater than 50
percent drop in cesarean sections, a remarkable drop in the
mothers’ need for pain medication, and several other
important and measurable benefits, which we describe in
the chapters that follow.

Being helped by the doula to breathe slowly and relax

through the contraction.
 This continuous support is provided by caring,
experienced women we call doulas. In searching for a term
to describe this role, we wanted a word with a nonmedical
connotation that would stress the value of a woman
companion as attentive and comforting. We turned to the
Greek word doula, meaning “woman caregiver.” Our first
exposure to the word came from Dana Raphael’s use of the
term to describe “one or more individuals, often female,
who give psychological encouragement and physical
assistance to the newly delivered mother.”12 We use the
word in the now widely accepted sense of an experienced
labor companion who provides the woman and her husband
or partner both emotional and physical support throughout
the entire labor and delivery, and to some extent,
afterward. Other people use terms such as labor coach,
monitrice, childbirth assistant, labor companion, or mother
assistant. Whatever the term, we hope our readers will
come away with an understanding of the vital shared
ingredient that makes this role so powerful and beneficial.
In this book we describe what a doula can provide both
during labor and birth and in the postpartum period, and
how she is trained. We discuss the results of our studies on
labor outcomes and differentiate not only between the
assistance of a doula and the equally vital help of fathers
but also between the work of the doula and that of the
nurse, physician, or midwife. We also offer guidance in
finding and evaluating a doula, and give, in Appendix A,
information on how a doula is trained.
We realize that a woman having a baby may be married
or single and accompanied by the father, her own mother,
or a close friend.When we use words such as father,
partner, couple, and parents, we mean to include all types
of family arrangements. Also, for simplicity, we use the
words mother and father, rather than mother-to-be and
father-to-be, for a woman and man as they share in the
experience of labor and delivery.

TYPES OF LABOR SUPPORT

When embarking on one of the most meaningful

experiences of their lives—the birth of their first child—a
couple fantasizes about what the labor and delivery will be
like. They may have a dream of how it will be—perhaps
hoping that this pregnancy and birth will be all their own,
something they do together without anyone else’s
interference. At the same time, they will have fears. On the
one hand, they may picture being alone together, with the
father being the main helper and support, and music
playing in the background as they go through labor without
interruptions or interventions and then have idyllic quiet
time with their new baby. On the other hand, they may
worry about pain, loss of control, problems for the baby, or
life-threatening complications.
Given these hopes and fears, all mothers and fathers
need emotional support and help during labor. Much of this
support they can provide to each other. The mother needs
to feel the father’s care, love, sense of connection,
responsibility, and sense of sharing in the intimate
experience of bringing their child into the world. The father
or other chosen partner has a strong desire to help, to
participate, to feel useful and active, and to feel important
and necessary for the mother.
But when two people share an emotional bond and an
ongoing relationship, it is very difficult for that companion
to remain continuously objective, calm, and removed to
some degree from the mother’s discomfort and fears, or
any danger to her. In most cases—and this cannot be stated
too often—the father will have the unexpressed but deeply