What Is a Birth Doula?

So, the second line showed up. Or, you knew the moment you woke up with the 18th high temperature. Either way, you have a little one on the way. Congratulations!

While this is a time of excitement for many, it can also be overwhelming. If you live in the Netherlands, you’ll have to contact a midwife. And then there’s the ultrasounds, the tests, the vaccinations, the sudden no-go foods and drinks. 

And of course, the main event, the birth itself. Here in the Netherlands, you can choose to give birth at home, at a birth centre, or at a hospital. Your birth team will include a midwife or gynecologist, a maternity nurse (kraamverzorgster),

… and maybe a birth coach, a doula.

Birth Attendants Throughout History

While births are mainly attended by a medical provider and the woman’s partner nowadays, that wasn’t always the standard. For most of history, birth was the domain of women. The laboring woman was supported by female friends and relatives, and often older women who were experienced in childbirth.  

In ancient Rome, for example, births were attended by a midwife and 3 female assistants. The woman would sit on a birth stool if one was available, and the midwife was there to guide the newborn out, sometimes turning the baby if necessary. Meanwhile, the mother was surrounded by the assistants: one on each side and one at her back. They helped her cope with the contractions and encouraged her.

During medieval times, midwives were responsible for the health of mother and child, but pregnant women would invite a group of close friends and relatives to support her throughout the birth. These attendants were called ‘gossips’, the original use of the word. They prepared the room, darkening the windows, stoking the fire, and made a special drink to strengthen the mother. 

In the 20th century, birth shifted from being viewed as a risky natural event to a medical condition that should be handled by medical professionals at the hospital. Interventions became common, especially in the US. These interventions were not always evidence-based, though, and sometimes resulted in traumatic experiences for the new mothers.

This created a demand for more “natural” birth practices in the 1960s. Many women wanted to be active participants in their births and started inviting trusted friends and childbirth educators to help them through labor, much like it was done for most of history. By the 1990s, this practice had become common enough for training programs to be established, and the doula profession was born.

Qualifications and scope of practice

Doulas are not part of the medical team. What do they do, then?

Think of a doula as your personal birth coach. She’s an independent practitioner, meaning she’s usually self-employed and directly hired by the mother, not the hospital. While the medical staff has many other patients to attend to, your doula will stay with you from the moment you call her until you’ve settled in after the birth. The doula can also stay with you even if your situation becomes medical and your midwife transfers your care to the hospital staff.

The midwife or OBGYN will check in on the progress and spot early signs of trouble, but often won’t stay until the pushing phase is near. Their focus peaks during the actual delivery of the baby; they need to check that the baby is healthy and the mother’s uterus shrinks back to a normal size. The doula’s focus is on helping the mother cope with the intensity of labor by reminding her to eat and drink, providing counterpressure, and talking her through the contractions. Being there from the beginning till the end allows her to spot subtle changes in the woman’s behavior. This helps her keep the medical staff up-to-date about what’s happening.

Doulas do not perform medical procedures, avoiding the inherent power imbalance between a patient and a doctor. She’s solely there to tend to the family’s needs, not to make judgements about the woman’s body. We do need professionals who can intervene when necessary, but having professional support without being “assessed” is often a welcome break.

A professional doula will have experienced many more births than the average person. She won’t be intimidated by the intensity or the many sounds and bodily fluids that accompany labor. This helps her reassure the woman and her partner, and guide the partner if they’d like to play an active role in supporting the woman. She’ll help you find evidence-based information and write down your birth preferences (birth plan) to smooth out communication with your medical team. She often knows the midwives and doctors in her area, as well as adjacent care providers, so you can benefit from her network.

The Evidence

With the increasing popularity of doula support, researchers have started studying the effects of adding them to the birth team.

There are studies about the effects of continuous support in general (any support person who stays with you throughout your labor), and doula support specifically. In 2017, 26 studies involving 15,000 people from 17 countries were compiled and analyzed.

Women with continuous support of any kind used less medical pain relief, implying that they were better able to cope. They also had a more positive experience of the birth overall. 

These women had:

• a shorter labor by 41 minutes on average
• a 38% decrease in the risk of low Apgar scores (a scoring system that helps determine the baby’s health at birth)
• a 25% decrease in the risk of C-sections, 39% if they were supported by a doula
• an 8% increase in their chances of giving birth vaginally without the need for interventions, such as a vacuum delivery. A doula increased their chances by 15%.

In the Netherlands, we have a very different system from countries like the US. You’ll be looked after by a midwife, unless you’re at a higher risk of complications and your care is transferred to the hospital. Giving birth at home is still relatively common, and thanks to our infrastructure and integrated midwifery care, it’s as safe as a hospital birth. Still, we do see benefits when women have continuous support:

• A reduction in C-sections from 12% to 6%
• A reduction in the use of epidurals from 37% to 24%
• An increase in spontaneous birth (no interventions needed) from 78% to 86%

As you can imagine, it can be tricky to study an intervention like this. Ideally, researchers would make sure neither the patients nor the care providers are aware of whether they are the ones who are getting the experimental treatment. Since we can’t do this when there’s a physical person caring for the mother, it’s impossible to design a study that is completely free of bias. However, the evidence does point to outcomes being better when doulas are present in the delivery room.

Where do you find one?

While any form of continuous support is welcome, a doula can offer extra benefits. If you’d like to have a doula at your birth, you’re probably wondering where to find someone with the skills you need.

Doulas and birth coaches are not protected job titles, meaning anyone can call themselves a doula. Some doulas have naturally entered the profession by attending births when they were asked by, say, massage clients. This is how a lot of the well-known doulas started back in the day.

However, nowadays doulas can get certified through local and international training programs. When looking for a doula to attend your birth, checking their certifications is a good place to start. 

In the Netherlands the NBvD, the Dutch association for doulas, oversees the quality of doula services. They recognize the following training institutions:

• Opleiding tot Doula, Utrecht
• BiA Doula Training, Amsterdam
• Doula opleiding In Bloei, Rotterdam
• Doula Academie, Monnickendam

Looking for a doula who is listed on the NBvD website or one of these schools will help you find someone who has the necessary skills, and will adhere to the code of conduct for doula services. You may also be able to get part of the care reimbursed through insurance if your doula has an AGB code.

Of course, you can visit my Doula Services page to see if I’m a good fit for you.

I hope I’ve helped you learn a bit more about your options for your birth and wish you all the best on your journey to parenthood.

Talk to you soon!