A woman's touch
The Spectator
Tue 21 Oct 2003
Page: G10
Section: Journal
Byline: Jeremy Laurance
Source: The Independent, London
Allowing men into the delivery room has been one of the great social transformations of our time. Four out of five births are now attended
by the baby's father but nobody has thought to ask whether their presence is helpful to the women.
Now, mothers are discovering the secret of a good birth is having another woman present.
The loss of female support in childbirth and its replacement by men could lie behind the soaring caesarean rate, which has doubled in 20 years.
A review of 15 research trials involving almost 13,000 women published in the Cochrane Library, the biggest source of evidence-based health care in the world, has demonstrated a female supporter is the best guarantee of a natural birth.
Mothers who had continuous support throughout labour from a woman trained to give that support needed less pain relief, had fewer "operative" births -- caesareans or forceps deliveries -- and had a more positive experience than those who received the normal attention of an often overworked midwife.
Professor Elaine Hodnett, of the University of Toronto, who carried out the review, said the presence of a trained supporter who was not employed by the hospital and whose only loyalty was to the woman in her care was a "very powerful" element.
"My bottom line is that women need and deserve close and continuous support in labour in an environment that is supportive. Many midwives will tell you they don't have the time to provide that, " Hodnett said.
"The key is the relationship the caregiver has to the woman. The evidence showed if continuous support was provided by a nurse or midwife it was less effective."
The idea is hardly new. Until 50 years ago, women typically gave birth supported by other women throughout their labour, and had done so since the dawn of time.
A mother, sister or neighbour would provide comfort and advice to assist the labouring woman through one of the most emotionally and physically demanding experiences of her life.
But from the middle of the 20th century, as doctors assumed control of childbirth and it moved from home to hospital, the tradition of providing continuous support to women in labour was lost. Birth became technology driven.
In place of the soothing presence of mother, sister or neighbour came the fetal monitor (to check the baby's heartbeat) with its blinking lights and nervy alarms.
The dehumanization of birth in the past half century has provoked one of the biggest protest movements in medicine.
Women have sought to wrest control back from the doctors and ensure labour and childbirth follow a natural trajectory rather than one determined by technical requirements.
But it has been a losing battle. The rate of interventions in childbirth -- involving induction of labour, anesthesia, forceps delivery, or caesarean -- has risen inexorably.
In Great Britain, figures published by the Department of Health in May showed that "normal" childbirth --without any intervention -- has for the first time become a minority activity.
Fewer than half of all new mothers -- 45 per cent -- now have a spontaneous labour and delivery. (Despite the World Health Organization's assertion that C-sections should account for no more than 15 per cent of births worldwide, in some major Canadian centres, the rate has soared to 30 per cent of births, or almost one in three babies.)
The trend has not curbed the demand for natural childbirth and now women are learning that hiring a female supporter may be the most effective way of obtaining it.
The idea of providing expectant mothers with a woman trained to support seemed to begin in the United States.
The female supporters are called "doulas" -- from the Greek for "servant" -- and it is estimated there are 40,000 doulas assisting women in the United States and Canada to challenge the technological tyranny of the medical birth.
In Europe, there are only a few doulas practising today, but demand is rising.
Doulas are not medically qualified but they have training ranging from a few days to nine months, depending on their previous experience.
Importantly, they are hired by the woman, not the hospital, to support her through labour, provide encouragement and praise as well as coping techniques and to represent the mother's wishes to medical staff.
They bring the voice of experience to a situation which, for new mothers in particular, may seem frightening or threatening. And, rather than threatening the role of husbands and partners, they may turn out to support them, too.
Anecdotal evidence suggests men welcome the presence of someone with experience who relieves them of responsibility, eases their anxiety and helps them play their part in the birth experience.
Doulas charge from about $600 Cdn to attend a birth which may last from a few hours to more than once round the clock.
Almost 30 doulas are working in the Hamilton area and they charge up to $600 -- but they may charge nothing at all.
Burlington doula Michelle Marion said the profession's code of ethics stresses that every woman who wants a doula should have one, despite her social or economic status. "Some doulas volunteer."
Marion said there is a growing interest in doulas, largely because women know they can't count on their own doctor being present for their child's birth and nurses change with each shift.
"A doula will stay with you throughout the labour," she said. "You meet her probably three months before the due date, if not earlier; you get to build a relationship and that person is guaranteed to stay by your side -- through shift changes and everything else."
At the final visit, most doulas present the mother and her partner with a birth story which consists of pictures and a written account of the birth as a memento, Marion said.
Mary Newburn, the policy director at Britain's National Childbirth Trust, said the Cochrane Review was "an absolute gem" and its findings "very important." (For more information, go to www.canadiandoula.com.)
She said: "It shows very clearly that one of the most effective things you can do to improve outcomes is provide women with continuous support during labour.
"It is extraordinarily effective in reducing caesareans, the need for pain relief and even how mothers relate to their babies after birth. It is one of the few interventions with hard evidence to show its benefit."
That view was backed by obstetricians who carried out a study at a hospital in the south of England in which 20 women were filmed throughout the course of their pregnancies and labours to record how many staff attended them and what they did.
The number of staff who cared for the women ranged from three to 11 and the midwives were seen to be spending more time filling in forms than sitting with mothers and talking to them.
The study, led by Keith Greene, consultant gynecologist and director of perinatal research at the hospital, concluded the demands on midwives to provide technically exemplary care, record it meticulously and give emotional support all at the same time were incompatible.
Loss of confidence in the care that is provided by current methods may have contributed to the rise in caesareans, it said.
The researchers ended with an appeal for greater recognition for the doula, whose role in promoting a good birth seems to now be beyond doubt.
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