The mother of all rows breaks out over doulas
Doctor questions benefit of female supporters at births
Like some ancient wounded creature, the male medical establishment occasionally lashes out in uncomprehending fury at "patient-led" developments in medical care that threaten to undermine its power.
In the latest example, an anaesthetist from Worthing Hospital has penned an invective in the esteemed British Medical Journal (BMJ) against the rise of the "doula", the female supporters who assist women through childbirth and whose popularity is growing rapidly on both sides of the Atlantic.
Around 1,000 doulas – the word comes from the Greek meaning "woman servant" – are thought to be practising in Britain, a three-fold rise in six years. They charge from £400 to £900 for a care package, which includes antenatal visits, labour, postnatal visits and being on call. The idea was imported from the US where there are more than 100,000 doulas who provide support to expectant mothers to challenge the technological tyranny of the medical establishment.
When Dr Abhijoy Chakladar had his medical authority questioned on the maternity ward at Worthing hospital, he admitted the experience was uncomfortable. He had suggested to the labouring mother, his patient, who was accompanied by her husband and a hired doula, that after he had topped up her epidural she change position and lie on her side to assist the spread of the local anaesthetic. The doula objected, saying the mother felt comfortable as she was, and she stayed on her back.
"I found myself disconcerted by the doula's presence as I was unfamiliar with her role. In retrospect, I should have confirmed everyone's roles and established ground rules acceptable to all ... In this clinical situation, the presence of a doula swayed the decision-making incorrectly," he wrote in a "Personal View" published by the BMJ.
He added: "The presence of doulas during labour may alter the doctor-patient dynamic and can compromise communication and therefore patient care ... The need for doulas implies a failing of medical and midwifery services. As the trend grows, a cynic might ask whether the doula business is actually necessary or whether it is exploiting – for profit – unspoken fears about NHS perinatal care and the seemingly limitless market for birth-related products and services."
Obstetrics has long been a battleground between the male obstetricians who dominate the specialty under whom birth has become technology-driven, and their female patients who have sought to wrest control back from the doctors and ensure labour and childbirth follow a natural trajectory.
It has been a losing battle so far as the women are concerned – half of all deliveries involve some form of medical intervention, such as induction, anaesthesia, forceps,or a Caesarean. The coveted "natural" birth has proved a difficult goal to achieve. But it has not curbed the demand and women have learnt that hiring a female supporter may be the most effective way of obtaining it.
Marcia Blackstock, managing director of Doula Consultancy Services, said Dr Chakladar was right to criticise the doula who interfered with the care of his patient, but wrong to dismiss the movement of which she was a part. "I would be appalled if one of my doulas behaved like that. We are very clear that doulas are there to give psychosocial support to the woman, and do not give a medical or midwifery opinion."
She added: "We need doulas because women want them. We do not replace midwives, we step back and provide support and let the medical team get on with providing the medical care. Research shows that they are effective."
A review of 15 trials involving 13,000 women published in 2003 showed that a female supporter was 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.
According to the researchers, from the University of Toronto, the key was the relationship the carer had to the woman. The evidence showed that if continuous support was provided by a nurse or midwife, it was less effective. Louise Silverton, deputy general secretary of the Royal College of Midwives, said: "There is no doubt that some doulas are performing a role that should be done by midwives. However, maternity services are seeing rapidly rising birth rates, increasingly complex births and midwife shortages. The pressure of work that midwives are facing means that too often they simply do not have the time to provide the kind of emotional support that doulas are offering."
Earlier this year, the Government announced £270,000 over three years for development of volunteer doula services in England.
Case study: 'I liked the idea of somebody being there for me'
Michelle Campbell's husband was working out of London when she was expecting her first baby, Luella, born last June, and she wanted the reassurance of knowing there was someone else who would accompany her to St Mary's hospital in Paddington, west London, when the moment came. So she hired doula Tracey-Anne Neil
"We got to know each other when I was three months' pregnant, and from two weeks before the baby was born she was on 24-hour call. I had never been in hospital for anything and I liked the idea of someone being there for me, who would relay my messages to the hospital staff."
Michelle said she had read about doulas on the internet and liked the sound of them. "I had my baby on the NHS, but it was almost like going private, because I felt there was someone in my corner for me. There were loads of midwives coming and going on shifts. I liked knowing that if I was left in the room because they thought I was doing OK and then things started happening, my doula could go into the corridor and shout for help."
Michelle went into labour at 6.30am, but with Tracey's experience was able to delay going to the hospital until she was ready to be admitted at about 2pm. "Tracey knew the procedure and timed my contractions. The mother next to me in hospital had been in and sent home twice because she was too early and she was hysterical. She ended up having a Caesarean. I was able to get up and walk around as I wanted, with Tracey's help, and I just had gas and air and Luella was born at 7.50pm."
Michelle's husband, Hugh Clarke, had arrived earlier, and the couple were able to cuddle the baby while Tracey made arrangements to get them a room of their own in the hospital. Michelle said: "She sorted all that for us. Hugh was with me, but there are times when it is quite nice to have another woman there. And she provided support for him, too, phoning to update him while he was on his way to the hospital and reassuring him when I was in pain. I would absolutely recommend a doula."
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