When Emme Dague Amble was 37 weeks pregnant with her first child, she went into labor. Her account of this experience is included in Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America by Christine H. Morton and Elayne G. Clift, a detailed look at childbirth practices that zeroes in on the difficult and sometimes contradictory roles played by members of hospital labor-and-delivery teams. It’s an inside glimpse since both authors are trained doulas, and their insights, research, and experiences—interspersed with narratives by women whose childbirths were aided by doulas—make for compelling reading.
“I wasn’t worried and was even a little relieved when my water broke during an afternoon nap almost three weeks early,” Amble begins. She further notes that she was given a prostaglandin when she arrived at the hospital, something she understood would speed up labor. In addition, unbeknownst to her, she was given Cytotec, a drug that causes extremely strong contractions. “At first,” Amble continues, “the labor began normally and our doula gently encouraged us with various comfort measures and we were casually laughing and chatting with her between contractions.” Several hours later, however, as the pain worsened, Amble says that she and her spouse began to worry that something was seriously wrong. On top of this, a hospital shift change meant that a whole new cast of characters needed to be apprised of Amble’s condition.
“I remember being aware of a crowd of people at the door of the bathroom looking at me with sympathy, as they tried to explain to the next group what was going on,” she recalls. “My midwife could barely squeeze by to get her fetuscope down to my belly to check on the baby. My husband shrank back into the corner to make room for staff to get by. Tears were streaming down his cheeks.” For her part, Amble recounts feeling scared and alone.
At that moment, she says, her doula swooped in. Moving close to Amble, she allowed the midwife to work while speaking to the patient in a tone that was simultaneously firm and gentle. “Her voice penetrated the chaos that surrounded me outside and within, and got my attention,” Amble wrote. “My doula did her job of caring for my physical need for comfort, focus, and rhythm which freed my husband to simply love me. … In turn, my midwife and nursing team could then do what they did best, to care for my medical needs and make sure the baby was safe. My doula’s voice helped me to gain control and work with the contractions instead of letting the pain take over and pushing me into panic mode.”
Amble ultimately delivered a healthy baby girl and credits her doula with helping her to avoid a c-section or other interventions.
But what does it actually mean to be a doula? According to Morton and Clift, doulas are birthing companions—women (and occasionally men) who are trained to provide ongoing, one-on-one, physical, emotional, and informational support to pregnant patients and their partners during labor and delivery.
DONA International, a 22-year-old Chicago-based organization, boasts more than 6,000 members, but as Morton and Clift make clear, doulas are presently unlicensed, so accurate figures on the number of people doing this work are hard to come by. At the same time, most doulas—fees range from nothing to between $400 and $800 per delivery—attend a four-day workshop to learn the basics of childbirth physiology and birthing practices.
Their role, say the authors, is critical. “Nurses, midwives, and physicians, as clinical providers, are unable to continuously attend to and prioritize women’s emotional and physical comfort throughout the entire course of labor and birth. Doulas, on the other hand, have defined their role to do precisely that in order to increase women’s emotional satisfaction with their childbirth experience.”
Still, the presence of doulas is rare; Birth Ambassadors estimates that they attend approximately 6 percent of U.S. births.
That said, studies confirm their positive impact: The presence of a doula reduces the overall caesarian rate by 50 percent, they write, and labor is typically shorter and completed with less pain medication. What’s more, they conclude that having an additional pair of eyes and ears in the room improves the woman’s treatment by hospital staff.
Nonetheless, the doula’s role is often tricky, and Birth Ambassadors does not shy away from addressing some of the difficulties that arise when they attempt to offer unconditional support to women, especially when said woman opts for things the doula thinks are unnecessary—for example, the artificial rupturing of membranes or a c-section. Elayne Clift calls this the “doula dilemma.”
“Our mission is to support the woman and honor her decisions,” she told RH Reality Check. “We can pose questions for the woman, but we’re trained not to say, ‘I think you’re doing the wrong thing.’ Instead, we open doors by asking questions. ‘Would you like to know more about that?’ for example. It’s always a tightrope walk.”
Christine Morton, in an email, adds that the role gets particularly thorny when the woman is in the throes of labor and simply wants the pain to end. “The doula has to figure out how to intercede when the patient changes her mind about an intervention,” she said. One tactic is to point out what she had previously indicated when she was constructing her birth plan. “The doula can ask a clarifying question, such as, ‘Do you have further questions about the risks/benefits’ of whatever has been suggested.”
And then there’s the issue of making sure that the woman has a good memory of the birthing experience. I ask if this ever feels like sugar coating. “Having a baby impacts a woman’s self-esteem and a positive experience impacts her early bonding with the child,” Clift explained. “Childbirth is enormously important, and you want the woman to have a positive recollection of it rather than look back and think, ‘If only I’d done this or that.’ The memory of giving birth never leaves us. We help women understand that they did what they could under the circumstances. I focus on the outcome, that she did her best and now has a newborn.”
Morton concurs, adding that it is “not up to the doula to point out what went wrong with a birth.”
Emme Dague Amble also weighs in on this and says that she is enormously grateful that her doula not only helped her put a satisfying spin on her daughter’s birth, but also gave her a typed chronicle of the entire process. The account, she writes, included “many tender moments between my husband and me, words whispered by my love that I had already forgotten. She preserved the beautiful moments of our birth story for us, when otherwise they would have been lost to me.”
Birth Ambassadors includes many other first-hand stories of doulas who went above-and-beyond to assist the women in their care. To a one, they are lovely and poignant.
So what is the future of this fledgling profession? Morton and Clift believe that the field will grow, as already evidenced by its expansion into other reproductive health-care services, including abortion. Nonetheless, they anticipate resistance—and for good reason. “Doula practice is radical,” they write, because it provides historical and clinical evidence for the personalization of birth and because it places women’s emotional experience at the center of this life event. Bringing this philosophy into the hospital is risky, even in the context of patient-centered care and shared decision-making, in part because doulas assert that most birthing women are not just patients, but healthy women going through a normal physiologic life event.”