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Wall Street Journal Article - Doula Controversy

As 'Doulas' Enter Delivery Rooms, Conflicts Arise Hired to Help in Childbirth, They Sometimes Clash With Doctors and Nurses

By SUEIN HWANG
Staff Reporter of THE WALL STREET JOURNAL

 
There's a new work force entering obstetrics wards. They are often strangers to the staff and unrelated to the patients. They aren't licensed and aren't required to have any formal medical training. And they are sparking protests in the medical community.

The workers are called doulas.

Named after the Greek word for slave, most doulas (pronounced doo-lah) are hired by expectant parents. Some just care for the mother at home after the baby is born. "Birth doulas" sit by the mother's side through the delivery, rubbing her back, suggesting alternate positions, listening to her fears and doing anything else that might help her through labor.

Many birth doulas advocate natural-birth methods that spurn common medical procedures, and from their post at the mother's bedside they are in a strong position to enforce that philosophy. Doctors complain that birth doulas sometimes persuade laboring mothers to reject Caesarean sections, medication and other treatments deemed medically necessary.

Obstetrician Christie Coleman was growing frustrated during a 2002 delivery at Lucile Packard Children's Hospital in Palo Alto, Calif. Her patient's membranes had ruptured days before. The doctor feared each minute was increasing the risk of an infection to the unborn baby.
[Christie Coleman]

For hours, Dr. Coleman says, she asked her patient to take the drug Pitocin, commonly used to help labor progress. Each time, the patient would send the doctor out of the room and confer with her birth doula. "I was spending hours trying to explain that this was for the baby's health, and it was just 'no, no, no,' " recalls Dr. Coleman, head of obstetrics and gynecology for the Palo Alto clinic of the Palo Alto Medical Foundation, one of Silicon Valley's largest medical groups. "I felt so powerless."

After being in labor for three days, the patient finally changed her mind and a few hours after the medication was administered, she gave birth. The baby, born with an infection, went to the intensive-care unit. "This beautiful little girl ended up needing a week of antibiotics and I felt horrible," says Dr. Coleman. The mother declined to be interviewed. Doulas are no longer welcome at the Palo Alto clinic.

Physicians aren't allowed to administer medical treatment without the patient's consent. In the case of a disagreement in which the baby's health is at stake, the doctor must either go along with the mother's wishes, offer the patient the option to be cared for by someone else if time allows, or in rare cases, request involvement of the court, according to the American College of Obstetricians and Gynecologists.

In most cases, birth doulas are helpful to laboring women, many doctors say. A growing number of studies have linked the attendance of lay people such as doulas to faster and easier deliveries and a reduced reliance on epidural anesthesia, Caesareans and other medical procedures.

Birth doulas have become particularly popular with older first-time parents, who tend to have higher disposable incomes. In big cities, where birth doulas are most often used, they charge anywhere from $800 to $1,000 or more -- generally for attendance at the birth, plus one visit before and after.

At least five national groups now offer doula training, which typically consists of a weekend workshop, writing an essay, reading books about labor and delivery and witnessing a couple of births. About 25,000 people have gone through training with Doulas of North America, the largest group, since it was founded in 1992. But anyone can say they are a birth doula; there is no certification or license required. No academic credential, such as a college degree or high-school equivalency, is generally required either.

By contrast, certified nurse-midwives -- who can deliver babies at a hospital without an attending doctor -- are nurses who must undergo an additional year or two of training in pregnancy and delivery.

Doulas and their supporters say the resistance they face from some doctors echoes previous conflicts between the medical establishment and advocates for change. "Natural childbirth wasn't a smooth go, and getting fathers into the delivery room was a huge battle," says Penny Simkin, co-founder of Doulas of North America. "It's always been a turf battle."
[Penny Simkin]

She says having a doula in the delivery room may help ensure that mothers' wishes are respected. "Some physicians want to be in charge ... sometimes leading the woman to believe there's a medical reason for a Caesarean or induction when there isn't one," Ms. Simkin says. "If there's a knowledgeable person -- a witness -- it's a little harder for doctors to do these things."

Many mothers say doulas helped them advocate for the kind of birth they wanted. Susan Linville, a Louisville, Ky., mother who had her first baby by Caesarean, says her birth doula persuaded her to switch doctors to find a practice that would support her decision to deliver a second baby vaginally. "I couldn't have done it without her," says Ms. Linville, who delivered her baby three months ago.

Kim Green, a writer in San Francisco, thought the "presence of a doula would mitigate the interventionist nature of a hospital birth." But there was another reason: She and her husband wanted a helper with experience. "We felt that attending a woman giving birth is not a job for a husband, necessarily."

The Washington-based American College of Obstetricians and Gynecologists doesn't have an official position on doulas, but a spokeswoman says it endorses support people in the delivery room "as long as they know what their role is in the delivery process ... that their major function is to provide psychological support to the mother."

With so many people now getting into the doula business, doctors say that a few are overstepping boundaries in ways that could be dangerous. In Austin, Texas, pediatrician and baby-care author Ari Brown says one of her patients recently phoned her birth doula first about an ailing newborn. The doula advised the mother to continue nursing and wait to see the doctor at a regularly scheduled appointment. By the time Dr. Brown was contacted, she says the baby's levels of bilirubin, a waste product created by the breakdown of red blood cells, was 18 milligrams; levels higher than 20 can cause deafness and brain damage in some babies.

"I really wish the mom called me instead of her doula," says Dr. Brown. "I think parents don't realize their doula doesn't have any medical training."

John Bagnasco, an obstetrician at Providence Health Center in Waco, Texas, says "some doulas feel their role is to act as an intermediary, which I find bothersome." He worries that in certain cases, a doula may be "providing medical opinions."

While birth doulas are still a new concept in much of the country, the clash is particularly evident in the San Francisco Bay Area, one of the epicenters of the natural-childbirth movement.

Patricia Robertson, professor at the University of California San Francisco's Perinatal Medicine and Genetics Division, which handles many higher-risk deliveries, says she's seen doulas "all but refuse" to let her examine her patients.

Doctors at California Pacific Medical Center, San Francisco's largest birthing hospital, say there have been several instances of babies who needed resuscitation after doulas persuaded mothers to delay Caesareans. Obstetrician Katherine Gregory says doulas have offered suggestions that are medically unfounded. Dr. Gregory says one doula at her hospital suggested that a patient who was in danger of bleeding to death might be cured by nipple stimulation. Another doula, she says, recently persuaded a patient to refuse accepting intravenous fluids, even through Dr. Gregory believed the patient was badly dehydrated.

Responding to staff concerns, California Pacific now distributes a list of recommended doulas. It inserted a clause in patient contracts saying that doulas must submit to the medical staff's decisions. More recently, the hospital began handing out similarly worded statements to every doula entering the ward. Because doulas are "involved in emotional support they can have tremendous influence on the patients," says Fung Lam, a doctor for 20 years at California Pacific Medical Center and a partner of Dr. Gregory's.

A little over a year ago, after attending a natural-birth class and reading extensively about childbirth, Laura Hall, a 35-year-old career counselor in Washington, decided to stay home during labor as long as she could. She hired a doula to advise her on when to go to the hospital and help with the delivery itself. As Ms. Hall's contractions worsened, she repeatedly suggested to her doula, whom she declines to identify, that the time had arrived. "She said, 'Oh no, you have lots of time,' " Ms. Hall recalls.

Four hours later, Ms. Hall realized she was really close to giving birth. She spent a frantic ride in the backseat of a car on her hands and knees. Minutes after arriving at the hospital, she delivered her baby boy. "I trusted that she knew more than I did," Ms. Hall now says. "It was not a smart thing to do."

Marshall Klaus, professor of pediatrics at University of California at San Francisco, co-published pioneering studies on the benefits of using birth doulas in the Journal of the American Medical Association in 1991. He later helped establish Doulas of North America. In training doulas, the group strongly counsels them against meddling with medical decisions. "Sometimes, even though we tell doulas frequently they are not to argue with a doctor, they do," Dr. Klaus says.

Last fall, at an Oxford Suites hotel in Yakima, Wash., nine doulas-to-be gathered for a three-day training session organized under the auspices of the Association of Labor Assistants and Childbirth Educators. The association, based in Cambridge, Mass., says it has trained about 4,500 doulas. Unlike other doula groups, this association doesn't ask its students to forswear involvement in medical decision-making. It also is more explicit about promoting the benefits of a nonmedicated birth.

As the scent of peppermint oil filled the air, Nancy Draznin, a doula and midwife from Genesee, Idaho, counseled her students not to go into the hospital "with their dukes up." But she also showed a video in which a mother tells how a male doctor arrogantly informed her she had just a 4% chance of delivering a baby vaginally and needed an unwanted Caesarean. "It happens a lot," said Ms. Draznin, who advised her students to wait until the doctor leaves the room and then encourage the mother to keep trying to deliver vaginally.

Ms. Draznin suggested insurance should pay for doulas, noting that hospitals charge $6,000 for a Caesarean. Her students responded that they believe doctors promote Caesareans because they will get more money by doing them. "There goes the new Porsche," said one.

Some new mothers and doulas complain that hospital staffers are hostile toward doulas. In 2002, when Jessica Kennedy was delivering her second child at California Pacific, she asked the doctor whether she could continue lying on her side. But when her doula tried to reiterate the point, the obstetrician refused to acknowledge the doula's presence, Ms. Kennedy says. She also thinks she received scant attention from hospital nurses because a doula was there. Ms. Kennedy, herself a labor and delivery nurse, helped establish a volunteer doula program at Kaiser Permanente, the San Francisco hospital where she works.

Felicia Roche, a doula who is on California Pacific's recommended list, says some nurses and doctors there still refuse to acknowledge her presence. A few months ago, she says, a nurse poked her in the arm and stormed out of the room when she was trying to help her client, who didn't want to receive fluids intravenously.

Ms. Roche, an Oakland, Calif., resident whose license plate reads "DOULAAA," points out that patients who hire her are more likely to question medical procedures. But whenever a patient is reluctant to proceed with a treatment, doctors and nurses often assume it is due to Ms. Roche's influence, she says. "I can't even tell you how often nurses think it's the doula's fault," she says. A California Pacific spokesperson responds that patient care and safety is the hospital's first priority.

Some hospitals have found a solution in creating in-house doula programs, using a regular group of doulas to work with birthing teams. Danbury Hospital in Connecticut subsidizes a program that offers doulas to laboring patients for a $100 fee. "In the beginning, physicians looked at us as like we were voodoo," says Sandy McGuire, program manager for women's services. "But as time went on, they started to see we're not after the nurses' jobs, and we're not trying to tell the physicians how to practice, and they realized that we are a benefit to them."

Write to Suein Hwang at suein.hwang@wsj.com

Updated January 19, 2004