Rachel Wickersham, RN, CPM, CD(DONA), LCCE, CLS
Doulas of Iowa City
Since the time of early humans, childbearing people gave birth at home surrounded by family and friends. They were supported in doing whatever they needed to do in order to cope and sustain themselves throughout the labor - eating, drinking, walking, swaying, vocalizing and using upright positioning.
In the US, birth began moving into the hospital in the early 1900s. Support people were excluded. Without support there was an increase in use of bedrest. This led to the need for medications to speed the labor and medications to manage the pain of bedbound labor. Birthing parents experienced fear and isolation. Complications increased and Cesarean Section rates began to rise.
In the United States the cesarean rate was 5.5% in 1970, 20.7% in 1996, and 32.7% in 2013 (1). Recognizing that an excessively high cesarean rate is associated with increases in maternal complications and death, US healthcare providers engaged in a national effort to reduce US cesarean rates but despite this, in 2021 the rate was still 32.1% and actually rose to 32.2% in 2022 (2). Rates of complications and even maternal mortality in the US are far higher than in most other developed countries and Black families are disproportionately affected with a 3x higher rate of maternal mortality than their white counterparts (3). In Iowa, the Black Maternal Mortality rate is currently 6 times higher (4).
In seeking a way to avoid unnecessary interventions and poor outcomes, some families turn to doulas for help. Doulas bring back the ancient support techniques that bring emotional comfort and promote labor progress, reducing the need for medication to stimulate labor (Pitocin) and reducing requests for pain medications. These in turn reduce complications and especially the rate of surgical delivery. Postpartum doulas care for the family in the home in the weeks following the birth, assisting with feeding issues, postpartum emotional adjustment and the practical matters involved in adding a new member to the family. Parents receiving doula care report higher satisfaction with their birth experience, increased confidence, improved postpartum mental health and improved breastfeeding outcomes. This is especially true when culturally congruent doula care is provided.
A large systematic review of continuous labor support summarizes the experiences of over 15,000 women who participated in 21 randomized controlled trials. Compared to women who had no continuous support, women who were provided one-to-one support by a companion who was neither a part of the mother’s social circle nor a member of hospital staff, benefitted in the following ways:
28% reduction in cesarean surgery
31% less likely to use oxytocin
9% less likely to use any pain meds
34% less likely to rate their birth experience negatively.
The authors concluded “Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.” (5)
Healthcare providers also recognize the benefit of doula care. The American College of Obstetricians and Gynecologists declares “Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor.” (6)
When it comes to breastfeeding, the doula difference is remarkable. An integrative review published in 2021 found a significantly higher rates of breastfeeding initiation when doulas were involved in the birth, regardless of the amount of lactation training the doula had received (7). Furthermore, a 2013 study showed women who had doula-supported births had near-universal breastfeeding initiation (97.9%), compared with 80.8% of the general Medicaid population. Among African American women, 92.7% of those with doula support initiated breastfeeding, compared with 70.3% of the general Medicaid population (8).
There are various types of doulas – Independent, Community-Based, Hospital Program and Volunteer. Each of these may work in private practice, group practice, or as part of an agency. Doulas are paid directly by parents or by hiring facilities or agencies. Funds for community-based programs come from private foundations as well as state and federal funding pools. Volunteer doulas are often given stipends by their program which is usually funded by grants and direct donors. In recent years there has been a push to allow Medicaid reimbursement of doulas and a number US states have passed legislation allowing this. Some programs are active, others like neighboring Illinois, are still working on rules. To date, Iowa has not yet passed such legislation.
US parents can find doulas at doulamatch.net as well as on websites for certifying organizations such as DONA International, National Black Doulas Association, ToLabor, CAPPA, ProDoula, ICEA and others. Across Iowa, four counties (Scott, Blackhawk, Dubuque and Polk) have programs initiated by Iowa HHS and funded by the US HRSA Title V Maternal and Child Health Service Heath Grant. The Iowa Black Doula Collective is a group that supports and mentors Black doulas across the state. In Johnson County, the Congolese Health Partnership has initiated a program to provide culturally congruent doulas to their community.
Across the Eastern Iowa Corridor area, independent doulas live and work. Some of these may be found in the local doula business networking group Doulas of Iowa City. DOIC provides support and fellowship for local doulas as well as a place to promote their businesses as a group. Parents-to-be can find DOIC on the web at the link above as well as on Facebook. Membership inquiries can be sent here.
Resources:
1 – CDC (2015). Births: Final data for 2013. National Vital Statistics Reports, 64(1).
2 – CDC (2023-June) NVSS Vital Statistics Rapid Release. No 28. Births: Preliminary Data for 2022
3 – CDC (2023 – April) – Health Equity Featured Article. Working Together to Reduce Black Maternal Mortality,
4 – Iowa Maternal Mortality Review Committee Process and MMRC Report. Iowa WIC All Staff Meeting 01-30-23, Iowa HHS.
5 - Hodnett et al. (2011). Continuous support for women during childbirth. Cochrane Database Systemati4 Reviews, Issue 2 , cited in Best research evidence on labor support, DONA International manual, 2017
6 – ACOG Committee on Obstetric Practice (2017). Approaches to limit intervention during labor and birth. Committee Opinion no. 687
7- Acquaye SN, Spatz DL. An Integrative Review: The Role of the Doula in Breastfeeding Initiation and Duration. J Perinat Educ. 2021 Jan 1;30(1):29-47. doi: 10.1891/J-PE-D-20-00037.
8 – Kozhimannil et al. (2013) Doula Care Supports Near-Universal Breastfeeding Initiation among Diverse, Low-Income Women. Journal of Midwifery & Women’s Health, 58: 378-382. https://doi.org/10.1111/jmwh.12065
Infographic Credit: DONA International:
https://www.dona.org/wp-content/uploads/2016/12/DONA_infographic-3.pdf
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