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CHILDBIRTH~2ndqtr11: Midwifery: The doula and midwife: a match made in heaven?

Childbirth UPDATE: ISSN 2222 6257

Michelle van der Westhuizen, Hons.B.A.(Psych), Dip. General Nursing Science, Midwifery, and Psychiatry and Community Nursing science, Certified Lactation Consultant (SA), a Certified Child birth Educator (experienced) ICEA (USA). Completed Vaccination training and holds a Permit 22, Hons. BA (Psych), Registered Councellor (Trauma Counsellor: birth trauma, trauma debriefing and postnatal depression screening).

In Greek ‘doula’ means ‘supportive companion’ (not a loved one) in labour. As early as 1973 Raphael described “optimal postpartum care for breastfeeding women” and reintroduced the concept of a post partum doula. In Greek midwife means ‘with women’.

Even though these concepts are ancient, they are still not understood and the doula is not utilised to full potential. In 2008 Sr Veronica Kaibe did her thesis to explore how the doula could assist the midwife. She discovered that many midwives do not understand the role of the doula, the importance of having a doula in labour (to the women) and the possible results of the doula’s presence during labour (V. Kaibe, 2008). Sr Kaibe believes that the presence of the doula lightens the load of the midwife and is a valuable resource in obtaining better birth and post partum outcomes.

A certified doula is a trained professional who sees birth as “a key life experience” (ICEA position paper on doula). The role of the doula is to support the couple, especially the mother, physically, emotionally and psychologically during labour. The doula provides continued support after the birth with lactation, maternal self care, parenting, locating resources and referring for the first 6 weeks after birth. The doula is not involved in any technical care and does not help with medical procedures. The doula’s rates, being less than the midwife’s, makes this service a more viable option for mothers needing post partum support.

The midwife (in South Africa) is also a trained and registered nurse. She/he has completed at least 4 years (often 5 years) of formal and practical training. The role of the midwife includes medical care, procedures, fetal monitoring, delivering the baby (depending on the maternity unit), initial care of the newborn and medical care of the mother post partum.

The doula’s role centers on providing for the new mother’s emotional needs. According to Hodnett (1998), providing this emotional support improves clinical outcomes in labour. Clinically the presence of a doula has shown to decrease the incidence of caesarian by 50%, the length of labour by 25%, use of pain medication by 38%, epidural with 60%, and forceps deliveries by 30% (Klaus, Kennell and Klaus, 1993). Women receiving post partum support were found to be more likely to exclusively breastfeed, have higher self esteem at 6 weeks after birth, have a more positive relationship with their partner and feel more satisfied with the outcome of the birth (Simkin, 1991). According to Kaibe (2008) the rate of post natal depression decreases when a doula supports the new mother.

According to Hodnett (1996) labour support includes five categories: emotional comfort measures, information, advice, advocacy and support of the partner.

Labour support has to be continuous for it to be effective (Berkowitz, Scott and Klaus 1999- cited in ICEA Position Statement and Review of Labour support). Traditionally midwifes are supportive and their care affects the psychological outcomes of labouring women (Green, Coupland and Kritzinger 1990-cited in ICEA Position Statement and Review of Labour support). In a study conducted by Tumblin and Simkin, 2001 (cited in ICEA Position statement and Review of Labour support) women expect the nurse to provide high touch care 29 % of the time, physical and emotional support 21% of the time, nursing care 21%, and 5% out-of-the-room care. Midwifes were found to provide physical support 9.9%, emotional support and instruction 6.1% of the time. The reason for this may be found in the wide variety of responsibilities fulfilled by the midwife. A labour ward is a just like any other hospital ward that necessitates administration, orders, receiving orders, charging stock, telephone calls, referrals, setting up and unpacking trolleys, cleaning, packing stock away, serving and ordering meals to patients, completing hospital and labour reports, training, CPR equipment and defibrillator checks, basic nursing care, organizing epidurals, locating doctors and other professionals, blood and specimens collection, processing and sending, fetal monitoring, giving medication, intravenous infusion initiation and monitoring, vital sign monitoring, assessing the patient, reporting any abnormalities and many other every day tasks. It should be clear why the midwife is not able to provide the high touch and emotional support required by the mother in labour. It may be a fair assumption that a certified doula would not only greatly aid the patient but also help when the midwife has more than one patient and many other responsibilities.

Gagnon and Waghorn, 1996 (Cited in ICEA Position statement and Review of Labour support and the Labour support person) found that the amount of years in nursing practice influences the nursing support given to the mother. Nurses who have been practicing for less than seven years give more support than those who have been practicing for longer. The support given by the nurse will frequently focus on technical procedures (ICEA position paper on labour support person). More research on the topic needs to be done, but one can expect burn-out to play a role in this phenomenon. Perhaps with the assistance of doulas, midwifes would suffer less burn-out and be more able to provide support to the labouring patients.

In modern society it has now become an expectation (allthough not in all cultures) for the father to be in the labour room. The expectation is that he be a companion, provide emotional support and be the labour coach taking charge of the birth. According to the ICEA position paper of Labour support we find that the father plays one of the following roles: the witness, the team player or the coach. Statistically the smallest percentage will take on the role of the coach, a slightly higher percentage the role of the team player and the majority the role of the witness. It was further found fathers tend to remain 30cm away from the mother during active birth at least 67% of the time. In contrast the doula was found to be touching the mother at least 95% of the time. Most women in labour (99%) see the father’s presence at birth as important. Future research would help us understand what we can fairly expect of fathers in the labour room. The ICEA position paper on labour support suggests that the best outcome for labour and birth is the dad plus the doula. This combination enhances the birth experience for both parents.

The role a doula can play to support the women in labour, her partner, better birth outcomes, better post partum outcomes and society as a whole is of great relevance. The doula can also play an important role in lightening the emotional load of the midwife, possibly preventing burn-out. I do believe it is in the interest of every woman, man, child and midwife to explore this resource to its fullest.

May there be a doula in every labour room and every post partum home!

*Doula Course - A 6 months part time course which includes a workshop once a month from 9am to 4pm. Students are required to attend relevant workshops, seminars and lectures on labour, birth and post natal care. The curriculum is extensive, covering topics e.g. labour support & comfort measures, breast feeding, HIV, professionalism and many others. New doulas are mentored by experienced doulas. They witness home births, water births, birth in state and private hospitals during their training. WOMBS doulas write a 3 hour exam at the completion of the course so as to maintain a professional standard.

The WOMBS DOULA Training is sponsored & supported by Johnson and Johnson.

Successful candidates who receive J&J bursaries need to give back to the communities by voluntarily supporting women in State facilities.

For more information
Barbara Hanrahan
Tel: 011 485 5895
Cell: 083 500 0062
Irene Bourquin
Tel: 021 852 3040
Cell: 084 330 9116

Women Offering Mothers Birth Support (WOMBS) is a registered doula organization for certified South African Doulas. With the aim of continuously updating their members and ensuring quality of care. WOMBS continue to benefit from the support of Johnson & Johnson who provide skilled update trainings and financial support towards the provision of bursaries. Contact: Sarah Meder Tel: 074 671 0952, visit: www.wombs.org.za.


  1. Assessing the role of a childbirth companion in the promotion of natural childbirth by Veronica Kaibe, (2008), Stellenbosch University.
  2. ICEA Position Paper: The Role and Scope of the Doula (1998).
  3. ICEA Position Statement and Review of Labour Support and the Labour support person.
  4. Hodnett, E. 1996. Nursing support of the labouring woman. Journal of Obstetric, Gynecologic and neonatal Nursing 25 (2): 257.
  5. Hodnett, E. D. 1998. Support from Caregivers during childbirth (Cochrane Review) In: The Cochrane Library, Issue 3.
  6. Klaus, M. H., J. Kennell, and p. Klaus. 1993. Mothering the Mother. Addison- Wesley publishing Co.
  7. Raphael, D. 1973. The Tender Gift: Breastfeeding. New York: Schoken Books.
  8. Simkin, P. 1991. Just another Day in a Women’s Life? Women’s Long-Term Perception of Their First Birth Experience. Part 2.
Posted on Friday, July 08 @ 11:29:37 SAST by E-Doc
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Childbirth UPDATE: ISSN 2222 6257

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