Labor of love: Doula care helps new moms

Helpers cut cesarean rate by more than half

Would you like to cut your facility’s cesarean rate in half,1-2 reduce the number of epidurals you give by as much as 85%,2 and market a unique maternity service to new customers? Then consider contracting with "doulas," minimally trained women who provide emotional support during labor or in-home support postpartum.

For the last 10 years, there has been a quiet revival of the long-practiced art of women helping women through labor and afterward. Today’s doulas (pronounced doo - laz, from the Greek for "female servant") are filling the gap that opened when women began giving birth in hospitals instead of at home, and when those hospitals, to cut costs, increased the number of new moms each maternity nurse was responsible for, says Deborah Pascali, executive director of the Center for Perinatal Research and Family Support in Westwood, NJ. Pascali laments that many daughters don’t live close enough to their mothers and grandmothers to get the support they once did.

"I think it’s a tragedy for families in the U.S. that we’ve changed our social structure away from the kind of support that was built into society 100 years ago," says Pascali, a doula who served as president of the National Association of Postpartum Care Services based in Edmonds, WA, and who is the owner of a doula service called MotherLove, also in Westwood.

Several well-established doula companies interviewed by Women’s Health Center Management say their goal is to contract with hospitals and birthing centers, so don’t be surprised if you are approached by a doula in the near future. Women’s health center managers we talked to, while mostly unfamiliar with doula services, expressed a strong desire to know more and to begin working with doulas.

No one is sure why labor doulas — those helping during birth — can reduce complications and the need for medication, but stress and anxiety are known to increase the secretion of catecholamine, which makes uterine contractions less effective and labor longer.3-4 And animal studies have shown that a mother’s emotional stress can affect fetal heart rate by decreasing placental blood flow.5-6 (For statistics showing the outcome of doula support, see chart, p. 12.)

Mercy Hospital, a member of the Henry Ford Health System in Detroit, initiated an in-house doula service after focus groups of women who had previously delivered there showed that the mothers were displeased with the absence of nurses and the unresponsiveness of the staff to their fears and concerns. Since the program began in the summer of 1995, patient satisfaction has boomed and the facility’s retention rate, measured in terms of women having prenatal care and giving birth at the facility, is higher, says Jamie Williams, assistant administrator of women’s and children’s services. As part of a woman’s birthing plan, each prospective mother is asked if she would like to have a labor doula present during the birth of her child. This is a free service to the community, Williams explains, adding that the hospital picks up the tab for the support when women want it. In 1996, the hospital spent about $30,000 on care provided by 10 doulas. Despite the cost, Williams recommends a doula program for other hospitals.

"Patient satisfaction is tremendous, and the staff is really appreciative of the doulas because they relieve them of a lot of work they would normally have to do," she says. "I think it is a very beneficial program."

Obviously the competition thinks so too; Williams says a hospital on the other side of town has just initiated its own doula service.

What you need to know

Creating The Fourth Trimester, a doula company serving the San Francisco Bay area, was a "marketer’s dream," because women were asking for the service, says co-owner Susan Pease. Since its inception in 1990, The Fourth Trimester has helped more than 1,000 families get through labor.

Pease says there are several ways you can get involved with doulas. One is simply to contract with an established doula company, but another way is to start a program yourself. To help you do that, here are some facts and figures provided by Pease and Pascali:

The ideal candidate is a woman who has some knowledge of postpartum care, has helped other women breast-feed, is knowledgeable about infant care, and understands the kind of support women and families need after birth, says Pease. They also need to be adaptable, good listeners, and self-motivated, she adds.

Individual doulas are paid hourly at a rate of about $10 to $12 per hour. Contracting with a doula company will cost about twice that much.

The first step is for the doula to meet with the couple prior to birth to discuss any concerns. Then the doula is on reserve for the couple, usually two weeks before and two weeks after the mother’s due date, says Pease.

Postpartum doulas perform many tasks, especially if they are dealing with first-time moms, says Pascali. Then the focus is on:

— infant feeding;

— infant care (bathing, diapering, and burping);

— making sure the mom is taking good care of herself and is eating well;

— care for the home (laundry and cleaning).

"We’re not a cleaning service, but we do what I call day-to-day stuff — that is the dishes, laundry, make beds, take garbage out, and cook meals," Pascali says.

Concept will be popular

Sally Rhoden, MA, program director for the Women’s Center at Promina Cobb Hospital in Austell, GA, says she has been approached by several doulas who wanted to make her aware of their availability to patients. There have been a few uses of labor doulas, when women requested them. But the hospital has a strong midwifery program, so most women don’t feel the need for the extra service, she says. Also, many women aren’t ready to self-pay for the service, but Rhoden expects the concept to eventually catch on around the country in the near future due to the lack of family support in society today.

That’s good enough for Pease. Women should know they have the option and that doulas are available to help them, she says.

Pease muses: "Wouldn’t it be wonderful for women to have a choice about their aftercare?"


1. Klaus MH, Kennell JH, Robertson SS, et al. Effects of social support during parturition on maternal and infant morbidity. Brit Med J 1986; 293:585-587.

2. Kennell JH, Klaus MH, McGrath S. Continuous emotional support during labor in a U.S. hospital. JAMA 1991; 265:2,197-2,201.

3. Lederman RP, Lederman E, Work BA, et al. The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. Am J Obstet Gynecol 1978; 132:495-500.

4. Zuspan FP, Cibilis LA, Pose SV. Myometrial and cardiovascular responses to alterations in plasma epinephrine. Am J Obstet Gynecol 1962; 84:841-851.

5. Adamsons K, Mueller-Heubach E, Myers RE. Production of fetal asphyxia in the rhesus monkey by administration of catecholamines to the mother. Am J Obstet Gynecol 1971; 109:248-262.

6. Barton MD, Killam AP, Meschia G. Response of ovine uterine blood flow to epinephrine and norepinephrine. Proc Soc Exp Biol Med 1974; 145:996-1,003.