This is one of the Lamaze Healthy Birth Practices.

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Jeanne Green, MT, CD(DONA), LCCE, FACCE, and Barbara A. Hotelling, MSN, CD(DONA), LCCE, FACCE

In a Lamaze class, a pregnant woman’s partner asks, “How can I provide the support she needs during labor? Will I have any help?”

In times past, women learned about childbirth from their mothers and sisters. Stories and family traditions helped women to have confidence in their ability to give birth. Family members and women friends surrounded the laboring woman, offering her encouragement and support. Babies were born at home with a midwife.

Then, early in the 20 th century, birth moved into the hospital. No longer could family or friends be present with a woman during labor. Nurses offered support, but they had to care for several women at the same time. Their responsibilities were divided among other patients, so the laboring woman was often left alone.

During the 1960s, Lamaze International and other childbirth organizations succeeded in changing the rules, so that fathers could be present in the labor room. Fathers give special, loving support to their partners and deserve to be there for the birth of their child. No longer did women have to labor alone.

Currently, women are rediscovering the value of having additional support during labor, especially from individuals who are experienced with and knowledgeable about birth. Women often assume that a nurse or midwife will stay with them throughout their labor. Sometimes this happens, but most often, other duties prevent care providers from being with only one person continuously. So, bring a loved one, a friend, or a doula with you for continuous support during your labor. You will receive the emotional and physical support you need from one or more caring individuals. Before your baby’s birth, decide who will provide this support, and make a plan with them.

For help with developing a plan for continuous support during labor, or if you have general questions, turn to Lamaze International—a recognized leader and essential resource for pregnancy, childbirth, and early parenting information.

Why Is Continuous Support Important?
Labor may surprise you (and your partner) with its power. If you are alone in labor, you might be scared or worried. This fear can increase your pain. It is helpful to have a knowledgeable person, such as a doula, who is experienced with birth and can tell you at any moment that what is happening is natural. No one likes to wait for reassuring care when one is afraid or hurting. A doula may sense when you need a comforting touch, when it is time to change positions, or when you can benefit from taking a walk. Continuous support may help you be more comfortable and help your labor progress.

The Role of a Doula
According to Penny Simkin (2008) in her book The Birth Partner, a birth doula “guides and supports women and their partners continuously through labor and birth” (p. 8).

A doula is trained in how to offer physical comfort and emotional support to laboring women. She provides information to help you make decisions and to plan for the birth you want. As you decide about the use of pain medication, she will support you. If you want to give birth without medication, she will help you. She will never be away from you for more than a few minutes, unless you want time alone with your partner. She may help you into a warm tub or shower. She may walk with you or suggest position changes. Perhaps she will massage your back, hands, or feet. After the birth, a doula usually stays with you to make sure things go well and to provide support as you begin breastfeeding your baby.

Doulas are not trained to perform any medical or nursing tasks. They should never offer medical advice. However, they will help you understand medical events. They can encourage you to talk with the hospital staff about your wishes. If your labor takes a different path than expected, a doula can help you sort out your feelings and discuss your choices.

One of the most important roles a doula plays is to help you have the best possible memory of your birth. After the birth, you will remember together the best parts of your birth experience. She will answer any questions you may have. If your birth experience did not go as you had planned, your doula will be there to listen to you and offer support.

The Doula and the Labor Partner
Most husbands or partners want to be present for the birth of their child. They want to be supportive. However, most men and some women are inexperienced with childbirth. As your contractions become more intense and you deal with pain, your partner may become frightened. He or she may not know whether your labor is progressing as it should. It may become more difficult for your partner to reassure you. Most partners breathe sighs of relief when an experienced childbirth professional, such as a doula, is present to assure them that labor is going just fine.

A good doula takes her cues from the labor partner. If your partner is sitting close to you, holding your hand, and providing eye-to-eye contact and supportive words, the doula will not interfere. Instead, she will support and encourage both of you.

However, if you need more support than your partner can give, the doula will work with your partner. She might give you a back or foot massage while your partner provides eye-to-eye contact and reassuring words. Or she may suggest a change of activity, a new position, or a comfort measure you and your partner have not tried. The doula can show your partner how to give counter-pressure or massage. She also can offer support while your partner takes a much needed bathroom or meal break.

Planning for Continuous Support
You may want a friend or family member to provide continuous labor support for you. Choose from those who have experience with childbirth and have confidence in your ability to give birth. They also must be willing to stay with you throughout your labor. Taking even a few childbirth classes together on how to give support in labor can have positive effects for you and your labor companion (Campbell, Scott, Klaus, & Falk, 2007).

Some hospitals or birth centers offer free or low-cost doula services. In this case, you may not meet your doula until you are in labor. If there is a language barrier between a laboring woman and the doula, both usually find that eye-to-eye contact and the doula’s gentle touch overcome the lack of a common language. Some hospitals provide a translator, if needed.

Many women find that hiring a doula is the best way to ensure they will have continuous labor support. In preparation for your birth experience, ask for doula referrals from your childbirth educator or your health-care provider. DONA International (www.dona.org) and other doula organizations offer referrals online. You may interview several doulas before you hire one. Plan at least one visit with your doula to discuss the birth that you hope to have. Share with her the features of your birth plan, approaches, and outcomes that are important to you and your partner.

Doula fees vary considerably. Some doulas also offer barter (trade) options or provide free services while working toward their certification. Few health plans pay for the cost of a doula (Lantz, Low, Varkey, & Watson, 2005). Call your insurance provider in advance to determine whether your health plan will pay for doula services. If not, help advocate for change by informing your insurance provider that, according to significant research findings, continuous labor support, such as services provided by a doula, decreases the likelihood of costly interventions such as cesarean surgery and the use of pain medications (Hodnett, Gates, Hofmeyr, & Sakala, 2007).

What Research Tells Us
Numerous research studies show important benefits to mothers and babies of continuous labor support by a loved one, friend, or doula. Labor support is a safe and effective practice with no negative side effects, yet the practice is underused (Sakala & Corry, 2008). According to a review of studies from the Cochrane Pregnancy and Childbirth Group—a part of the highly respected, international Cochrane Collaboration that identifies best care practices based on research—continuous support for women during labor and childbirth is clearly beneficial (Hodnett et al., 2007). Study findings indicate that, compared to women who do not receive continuous labor support, women who receive continuous, one-to-one support are less likely to:

• have cesarean surgery;
• give birth with vacuum extraction or forceps;
• have regional analgesia (e.g., an epidural);
• have the need for any analgesia (pain medication); and
• report dissatisfaction with or negative feelings about their childbirth experience (Hodnett et al., 2007).

Two previous reviews of the research on continuous labor support had similar findings (Leslie & Storton, 2007; Simkin & O’Hara, 2002). The authors of all three reviews found that, compared to care from hospital staff nurses or midwives, continuous labor support is more effective when the person providing labor support is not a member of the hospital staff (Hodnett et al., 2007; Leslie & Storton, 2007; Simkin & O’Hara, 2002). In one review, increased benefits were found when continuous support started early in labor (Hodnett et al., 2007).

Research findings suggest that the benefit of labor support has no economic or cultural boundaries. In one study, continuous support reduced pain for low-income women who would have labored alone if they had not had a doula present (Simkin & O’Hara, 2002). Another study found that fewer cesarean surgeries and less need for epidural analgesia occurred when middle-class, laboring women and their male partner had the support of a doula (McGrath & Kennell, 2008). The same study also found that women and their partners were more satisfied with their birth experience when a doula provided support. Higher rates of early initiation of breastfeeding were found in an urban, multicultural setting when a doula was present (Mottl-Santiago et al., 2008).

Recommendations from Lamaze International
Women need a community of support around them during pregnancy and childbirth. Family members, friends, doctors, nurses, midwives, doulas, and Lamaze educators all play a vital role in helping to achieve safe and healthy birth outcomes. Lamaze International joins the World Health Organization (Chalmers & Porter, 2001) in recognizing the value of continuous labor support. Lamaze recommends that women bring a loved one, friend, or doula for support during labor and birth. The key is to have someone with you continuously throughout labor. Plan for a supportive birthing environment, carefully considering those whom you want to help you.

A supportive woman—such as a doula—experienced with childbirth can help you in many ways. She is able to give you and your partner information and to offer emotional and physical support.

Everyone wants to see positive birth outcomes. To help achieve these outcomes, Lamaze teaches women to be confident in their childbirth decisions and communicate their needs to everyone involved. Lamaze helps a woman think through her needs and desires for childbirth and equips her to choose a birth team that will truly support her goal of having a safe and healthy birth. Lamaze International believes that continuous support should be available to every laboring woman, without financial or cultural barriers.

To learn more about safe, healthy birth, read The Official Lamaze Guide: Giving Birth with Confidence (Lothian & DeVries, 2005), visit the Lamaze Web site (www.lamaze.org), and sign up to receive the Lamaze…Building Confidence Week by Week e-mails.

Most Recent Update: May 2009

References
Campbell , D., Scott, K. D., Klaus, M. H., & Falk, M. (2007). Female relatives or friends trained as labor doulas: Outcomes at 6 to 8 weeks postpartum. Birth,34(3), 220–227.

Chalmers, B., & Porter, R. (2001). Assessing effective care in normal labor: The Bologna Score. Birth,28(2), 79–83.

Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2007). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub2 (This review is available at no charge on the Childbirth Connection Web site at http://www.childbirthconnection.org/pdfs/continuous_support.pdf)

Lantz, P., Low, L. K., Varkey, S., & Watson, R. L. (2005). Doulas as childbirth paraprofessionals: Results from a national survey. Women’s Health Issues,15(3), 109–116.

Leslie, M. S., & Storton, S. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 1: Offers all birthing mothers unrestricted access to birth companions, labor support, professional midwifery care. The Journal of Perinatal Education,16(Suppl. 1), 10S–19S.

McGrath, S. K., & Kennell, J. H. (2008). A randomized controlled trial of continuous labor support for middle-class couples: Effect on cesarean delivery rates. Birth, 35(2), 92–97.

Mottl-Santiago, J., Walker, C., Ewan, J., Vragovic, O., Winder, S., & Stubblefield, P. (2008). A hospital-based doula program and childbirth outcomes in an urban, multicultural setting. Maternal and Child Health Journal, 12(3), 372–377.

Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve. New York: Milbank Memorial Fund. (This report is available at no charge on the Childbirth Connection Web site at http://www.childbirthconnection.com/pdfs/evidence-based-maternity-care.pdf)

Simkin, P. (2008). The birth partner. Boston: Harvard Common Press.

Simkin, P., & O’Hara, M. (2002). Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, 186(Suppl. 5), S131–S159.

Acknowledgements
This healthy birth practice paper was revised and updated by Jeanne Green, MT, CD(DONA), LCCE, FACCE, and Barbara A. Hotelling, MSN, CD(DONA), LCCE, FACCE.

The six healthy birth practice papers were originally written in 2003 by Lamaze International as the 6 Care Practice Papers.