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 labor 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 labor 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 labor 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 labor, rate the birth experience as good and say that enduring labor 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 labor 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 labor 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 labor, 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 labor, 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 labor, 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 labor 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.
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