What's a doula? What do—and don't—they do during childbirth?

A birth doula is a personal support person that women can hire privately during pregnancy, typically attending the birth to offer nonclinical comfort measures like massage, assistance with positions, and emotional reassurance. Some doulas extend their support to the postpartum period. While the term originates from ancient Greek meaning female servant or slave, modern doulas are professionals who run businesses and are compensated for their services.

The word doula gained popularity in the US during the 1970s, revived by medical anthropologist Dana Raphael, to describe women who supported breastfeeding mothers. Early research conducted by Marshall Klaus and John Kennell in Guatemala demonstrated that births with supportive female companions had shorter durations and lower rates of cesarean sections.

This finding led to the publication of the 1993 book "Mothering the Mother" and the term doula's inclusion in the dictionary in 2003. Although nonclinical labor support has been present in Australia for years, the demand for doulas started rising in the early 2000s. Anecdotal evidence suggests that this trend has continued. A 2018 California survey found that 9% of women employed a doula, with this rate being higher among Latina and Black women.

Training for doulas varies significantly, ranging from a brief workshop with no ongoing mentorship to a one-year program involving mentorship. The cost to hire a doula can range from approximately A$500 for a trainee doula to over $5,000 for highly experienced doulas. The cost is influenced by factors such as the doula's level of training, experience, and the services provided, such as being available for the birth.

Research has shown that continuous doula-like support during labor can lead to higher rates of vaginal births, reduced usage of pain medications, shorter labors, and lower incidences of low five-minute Apgar scores. The reasons for these positive outcomes are not fully understood but may involve increased oxytocin production, enhanced mobility during labor, and improved confidence and self-esteem.

However, it is unclear whether these benefits are solely due to the doula or if they are also associated with continuous midwifery care. A 2011 study examining midwives' and doulas' perspectives on the doula's role found that the maternity system was not adequately meeting women's needs due to high clinical workloads and insufficient continuity of midwifery care.

Doulas were seen as filling this gap, but midwives felt that doulas were encroaching on their role and being reduced to performing clinical tasks. Some conflicts arose when doulas exceeded their role and provided medical advice that contradicted that of the clinicians. Despite the clear benefits, some providers have been resistant to or untrained in utilizing doulas, leading to potential conflicts.

Doulas should not replace midwives or obstetricians in childbirth, as evidenced by tragic outcomes in freebirth scenarios where doulas attended without midwifery or obstetric supervision. Currently, there is no national body that sets standards or holds doulas accountable in Australia. However, complaints can be lodged through state-based health complaints commissioners or the Health Ombudsman, depending on the location.

In cases where a mother or baby dies, the matter would be investigated by coronial authorities or the police. When working alongside maternity professionals, doulas can provide valuable emotional support, leading to positive outcomes for both women and babies, particularly for those who cannot maintain the same midwife throughout pregnancy and labor.