It’s 2 o’clock on a Friday morning and mom-to-be Kim Morris is in labor in her Menlo Park, California home.  As she leans on a kitchen counter for support, a calm woman in her mid-40s with straight blond hair, stands by rubbing the sides of Morris’s belly and giving her words of encouragement. The woman helping Morris though her contractions is Perryn Rowland who Morris hired to help her through the delivery of her child.  Rowland is a doula, a non-medical childbirth assistant. Unlike doctors, who often don’t arrive until the baby is about to be delivered, doulas stay with the mother during the entire labor.  Rowland accompanies Morris and her husband to the hospital. She coaches Morris as she stands under warm water through the rest of her contractions.  Rowland stays by Morris’ side during eleven hours of labor, until she gives birth to a healthy 7 lbs, 9 oz. baby girl.

Rowland says she provides a service that some doctors can’t offer.

“So many people are in big medical groups and they don’t necessarily have that relationship with their care provider that they want,” she says. “They just want somebody who’s not going to leave them.”

The largest doula association, DONA International has seen a growth in membership from 750 in 1994 to more than 6,000 in 2006.  Research from 17 published randomized trials including the Journal of American Medical Association has shown that women who have doulas with them during their entire delivery cope better during childbirth compared with women who don’t have assistance.  A recent Cochrane Review, Continuous Support for Women During Childbirth, found that “continuous labor support reduces a woman’s likelihood of having pain medication, increases her satisfaction and chances for ‘spontaneous’ birth, and has no known risks.”   The women have fewer incidents of C-sections, they may be able to avoid epidurals or other pain medicines, they spend less time in labor and they have lower rates of postpartum depression.  The differences did not hold for women who had doulas that left for an hour or more during the labor.

“She was able to do things for me that I would have forgotten to do if I was there alone,” says Morris on why she chose to hire Rowland for her second pregnancy.  “The doctor is in and out. And the nursing staff changes their shifts. [Rowland] was there from the beginning to the end.”

Childbirth can be a scary experience for new parents. Having a doula can provide physical and emotional support before, during and immediately after childbirth.

Dr. Marshall Klaus of the University of California San Francisco says a childbirth assistant– especially one who uses firm touch or massage– helps the laboring woman release oxytocin.  Oxytocin is a hormone secreted by the pituitary gland that reduces stress and pain, and acts like a calming drug for women in labor.

While the assistance of doula has benefits, it can have a steep price tag.  Standard doula services include meeting with the family before the birth and after, and being on call for the labor regardless of the hour.  Parents can attend a “meet the doula night” to interview and get to know a doula so that they can pick someone they feel comfortable with.  Doulas often are involved in coaching months before the delivery day, and postpartum doula services are also available.  In 1996, health advocates in Chicago began working to make doula services accessible to low-income mothers and teen moms, and they trained women from these groups to serve as doulas for one another.  The program provided thousands of people with extended doula services, and program organizers decided to replicate the project in other cities, including Atlanta, Albuquerque, Minneapolis, Phoenix, Denver, Indianapolis, Seattle and Bloomington.  More programs are also under development in New York, San Francisco, Berkeley, Fort Worth/Dallas, Baltimore, Washington, DC, and Bethel, Alaska.  These programs offer free or reduced cost doula services, and often train women to serve as doulas in their own local communities.

Relevant web links

• New Cochrane Review on Effects of Continuous Labor Support – http://www.maternitywise.org/prof/laborsupport/index.html
• The First National U.S. Survey of Women’s Childbearing Experiences – http://www.maternitywise.org/listeningtomothers/index.html
• DONA INTERNATIONAL and DONA doula certification – http://dona.org/ (888)788-DONA
• Chicago Health Connection Doula Model (community-based doula model): http://www.chicagohealthconnection.org/our_work/doula/about.php http://www.chicagohealthconnection.org/doula/nati_repl.htm
• A Doula Story (the film):  http://www.activevoice.net/doula.html
• Alternative Doula Certification programs: International Childbirth Education Association – http://www.icea.org/doula2.htm

Relevant book:

The Doula Book: How a Trained Labor Companion Can Help you Have a Shorter, Easier, and Healthier Birth. By Marshall H. Klaus, Phyllis H. Klaus and John H. Kennell.

Few women in labor, awaiting the birth of a baby, spare a moment to think of their state legislature. But they might be surprised to learn that, increasingly, state legislatures across the United States are thinking of them.

Following the passage in April of a reform bill legalizing the supervision of home births by certified professional midwives (CPMs) in Wisconsin, similar reform efforts are now underway in no fewer than nine states.

Alabama, North Carolina, Idaho, South Dakota, Illinois, Kentucky, Georgia, Missouri, and Indiana all await legislative debates that could lead to the licensure of certified professional midwives, says Ida Darragh, chairman of the board of the North American Registry of Midwives (NARM), the national organization that tests and registers CPMs.

Legalization and licensure of CPM practices in all these states would represent a massive legislative victory for advocates of traditional home birth.

It would also be a startling rebuke to the many physicians who have long maintained that such practices are unsafe, despite growing statistical evidence that suggests CPM-supervised home births are as safe – sometimes safer – than hospital births.

Well-organized opposition within medical lobbying groups makes such a one-sided result unlikely within the next two years, Ms. Darragh says. But, when asked if the flurry of activity in the nation’s statehouses is indicative of a national trend in support traditional childbirth methods, she adds: “We certainly hope so.”

As with many health issues, the debate about CPMs may seem arcane to non-experts. The debate is a minefield of acronyms, and home births account for just 1 to 3 percent of all births in an average year, with similar percentages in each state.

Yet the debate casts in sharp relief a philosophical tug-of-war over the nature of childbirth that powerfully affects how expectant mothers approach the ordeal of birth.

Elsewhere as in Wisconsin, this tug-of-war pits midwives and physicians who support “natural childbirth” outside the hospital setting and with minimal intervention against the many physicians and nurses who view medical birthing techniques as safer.

When Wisconsin’s reform takes force in May 2007, Wisconsin will become the 23rd state to institutionalize a way for expectant mothers to reject a medical birthing culture entrenched since the 1950s.

Activist midwives say the Wisconsin reform adds bulk to a growing body of circumstantial evidence that America’s popular view of childbirth is in flux, with parents adopting new perspectives on labor and the role of modern medicine in it. CPMs describe labor and birth as “natural” events rather than medical emergencies necessitating medical intervention.

“I think it is a trend,” says Katherine Prown, legislative chair of the Wisconsin Guild of Midwives. “We have seen Minnesota, Utah, Virginia and now Wisconsin all pass laws since 1999. There is a lot of momentum behind these bills.”

Traditional midwifery is struggling to reemerge from the obscurity in which it has languished since passage of Medical Practice Acts (MPAs) by all 50 states, in the 1950s. These acts criminalized the “practice of medicine” by unqualified individuals. They need not have impacted traditional midwifery, but they did in 49 states because only Mississippi offered an exemption for midwives, Ms. Darragh says.

Yet whatever the movement’s momentum, there is also powerful opposition. The American College of Obstetricians and Gynecologists (ACOG), a well-funded proponent of childbirth in the hospital setting, opposed the Wisconsin reform, publishing a position paper stating that CPM-supervised home birth “cannot be considered safe”.

ACOG also urged state officials to take “immediate aggressive action” against “unsafe birth practices”.

Such action was seen earlier this year in Indiana, where state prosecutors earlier this year charged Jennifer Williams, a CPM, with practicing medicine without a license. Ms. Williams, who says she helped 1,500 women give birth safely before she faced any charges, pled guilty. She has since filed a lawsuit against the state attorney general, asking an Indiana circuit court to distinguish between midwifery and “the practice of medicine.” Ms. Williams is also part of the group campaigning for legalization and licensure of CPM practices in Indiana.

The divergence in approach between Wisconsin’s legalizers and Indiana’s prosecutors shows the wide variety of options available to legislators and regulators. States have essentially three options: to legalize, license and regulate the work of CPMs as Wisconsin and 22 other states now do, to prosecute CPMs as Indiana and some others have done, or to turn a blind eye as Mississippi does.

Democratic pressure on statehouses throughout the country could one day yield a consensus, either in CPMs favor or against them. In the meanwhile, those embroiled in the debate are confronted with a growing body of scientific research.

One study frequently cited by CPMs was published last year in the British Medical Journal, an academic publication, by Kenneth Johnson, senior epidemiologist for the surveillance and risk assessment division of Canada’s Center for Chronic Disease Prevention, and Betty Anne-Daviss, a project manager at the Ottawa-based International Federation of Gynecology and Obstetrics.

The study reviewed records of all CPM-supervised home births in North America in the year 2000 and led Dr. Johnson to conclude that “planned home birth for low-risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intra-partum and neonatal mortality to that of low-risk hospital births in the United States.”

Asked to provide any statistical evidence contradicting such studies, for the sake of this story, ACOG sent none but e-mailed two policy statements further explaining the organization’s position on the certification of midwives.

Links:

• American College of Obstetricians and Gynecologists – www.acog.org
• North American Registry of Midwives – www.narm.org
• Wisconsin Guild of Midwives – www.wisconsinguildofmidwives.org
• Study published in British Medical Journal (see third-to-last paragraph of story)  – bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom
• British Medical Journal – bmj.bmjjournals.com