Childbirth in the United States was once in a very dire place.  The outcomes for mothers and babies were poor to dismal (like in our part of the country - rural Appalachia).  However, it did not remain that way.  Pioneers in the care of women and children such as midwife and founder of the Frontier Nursing Service, Mary Breckinridge worked hard to change that.  Improvements in care included above all an approach that centered upon education of the women, their families, and their caregivers.  Using this approach, Breckinridge achieved better outcomes in her service than the physicians of the day were achieving in the hospitals.  
     The reality of childbirth improved for women in the US for a time.  There have been dips and surges in the safety of childbirth and the outcomes of birth for mothers and babies, but what is concerning at the present is that the US and Canada both are "low on the list of optimal perinatal and maternal outcomes" when it comes to industrialized countries and even some developing countries (Klein, The Journal of Perinatal Education, 20(4), 185-187, 2011).
    Many attribute this change and poor outcomes for mothers and babies to the high rates of surgical birth (c-section) in the US - 34% or 1 in 3 women.  But, a recent study conducted in Canada by Dr. Michael C. Klein, MD, CCFP, FAAP revealed that "a substantial number of women, even late in pregnancy, were uninformed about the risks and benefits of key procedures and approaches that might be used in birth."  Dr. Klein wrote an editorial about his findings and his recommendations to address those findings in the most recent edition of The Journal of Perinatal Education cited above.  He also stated that, "Only 30% of the women had attended childbirth education classes; books and the Internet were their main sources of information."
     Looking at the sources of information women are accessing during pregnancy and the fact that so many remain uninformed show a possible lack of finding truly useful or reliable information from the books they choose and the websites women visit and a disconnect between women and their care providers when it comes to patient education.  There are many great books and websites for pregnancy and birth, but there are also many inaccurate information sources.  We also have seen a reduction in the number of care providers offering complete childbirth education either through their private practice or the birthing facility.  Many "childbirth classes" meet only a few times and include basically what to expect when it comes to hospital routine and policy as well as a tour of the maternity ward.  These are important classes for women to take so that they can be prepared and anticipate certain experiences during their birth, but there is also a great need to have complete childbirth education including pregnancy nutrition/exercise, stages of labor, comfort techniques for labor including both natural and medical coping strategies, possible medical interventions that might be necessary and the risks and benefits of each, breastfeeding, postpartum, newborn procedures, and early newborn parenting.  In order to cover all of these topics, it is imperative that women and their support persons meet with their educator over an extended period.  Many childbirth educators who are certified through the various organizations in the numerous styles of education have a required amount of hours or equivalent of those hours that they must meet in order to label their classes as - Lamaze, Bradley, Hypnobirthing, Brio, CAPPA, ICEA, etc...  This hourly requirement ensures that educators and the women they serve have the necessary time to cover all of these important topics that allow women to have the ability to act on the information they receive.
     Another very disconcerting aspect of Dr. Klein's study revealed that obstetricians younger than forty "were less favorable to birth plans, less likely to acknowledge the importance of the woman's role in her own birth experience, and more likely to view cesarean surgery as 'just another way to have a baby'.  They were also more likely to believe that women who had cesarean surgery 'did not miss an important life event.'"  Physicians also had misinformed beliefs on cesarean surgery being "as safe or safer for mothers and babies as vaginal birth" - 20%.  "Half of OBs were not supportive of doulas, and 70-80% of providers felt that home birth was unsafe.  Epidural analgesia was another area where many providers, especially obstetricians, felt that the procedure did not interfere with labor or increase the frequency of instrumental birth (Klein)."  This is despite the scientific evidence showing the contrary on all of the four points above.  Klein points out however, that it is important to recognize that 20% of the OBs in the study had attitudes that aligned with midwives.  So, we see that though a minority there are OBs who feel otherwise about routine intervention and the risks involved in normal birth.  Klein found that women who were attending midwives for their care were less favorable to the use of technology and more supportive of women's roles in their birth experiences, possibly illustrating the difference between the obstetric and midwifery model of maternity care.  
The following photo is linked to an interview with Julie Daniels, CNM of Frontier University describing the difference between the obstetric and midwifery models of care.  This post is continued after the jump.  
 

Dr. Klein questions "how informed decision making can take place when so many women approaching their first birth are ill-informed and so many care providers think they know, but what they believe is not evidence-based."  Many organizations invested in childbirth education are making strides to empower women with scientifically based information, such as Lamaze International and their Six Healthy Birth Practices campaign.  But, Dr. Klein also asks, "how can you make a revolution when so few individuals are unhappy with current maternity care practices?"  Dr. Klein believes that "The most unhappy and well-informed women select midwives, if available.  The most fearful women select obstetricians."  This may be so, but we must figure in the cultural norms and the fact that so many women are ill-informed.  (I was one of those ill-informed women during my first pregnancy.)  The famous quote from Diane Korte and Roberta Scaer, "If you don't know your options, you don't have any", says it all.  Interjecting my personal experience here, I can't tell you how many times I get confused with being a midwife when I tell people that I am a doula.  This is even after I describe what it is that I do and that it involves no medical or clinical responsibilities.  There is so much misinformation that many don't understand what a midwife even does.  This information is residual from the smear campaign of midwives in this country throughout the early 1900s, taking midwives from the primary maternity caregiver to almost non-existent.  Not that OBs are not great birth attendants.  We need OBs and their services very much.  OBs are trained surgeons and are trained to manage high-risk situations.  In many situations, they are the best possible care provider.  We need cesarean surgery to be available when it is medically necessary, but we also need to know that just like open heart surgery it is not physiologically normal and should be reserved for emergencies and true medical necessity and not used as a prophylactic.  In a systematic review, there were 33 areas were c-section was found to cause more risk than vaginal birth and 4 areas where vaginal birth was found more risky than c-section.  Surgery is never a walk in the park.  We can be thankful that c-section is a relatively safe major abdominal surgery, but we need to recognize it as surgery.
     But, the real issue to address here is women having access to the information they need to make informed decisions and then the support they need to access their options.  The beginning is the recognizing of a need for information.  It is the recognizing that women deserve better.  It is understanding that childbirth is a normal bodily function of the female body, and should not be treated as an illness, but as a very special time in which extra attention must be paid to health, safety, comfort, and proper support.  What raises this recognition - education.  It is so important for educators to reach both women and their care providers, for we are all working toward the same things - as positive outcomes as possible in individual situations, and satisfaction and dare I say pure joy in the experience of giving birth.

The vision statement of DONA International, the organization from which Heather and I received our training, is: A doula for every woman who wants one.  This holds quite a bit of value.  The standard fee for doulas vary depending upon the city/town where the doula is working and can be anywhere from $1,000 or so to as little as a few hundred or so.  There are also varying skill sets and levels of experience that doulas have that can impact the fee that they charge.  
The big question is - Are the benefits of a doula worth the money I'll have to spend for her services?
Dr. John Kennell, MD one of the founders of DONA International stated, "If a doula were a drug, it would be unethical not to use it."  In his work (along with the other founders of DONA) with pregnant/birthing women and babies, he noticed the positive impact that continuous physical and emotional support had on the laboring woman.  This support was beneficial regardless of the type (non-intervention, intervention, or necessary intervention) birth the mother was having.  It was even noticed that having this support could help a woman avoid unnecessary medical intervention in birth and increase her satisfaction with the process of birthing.  Kennell and his colleagues chose the term "doula" to describe this woman to woman support.
Research into the impact of a doula on the outcome of birth has shown that the presence of a doula can:

• result in shorter labors with fewer complications
• reduce negative feelings about one’s childbirth experience
• reduce the need for pitocin (a labor-inducing drug), forceps or vacuum extraction
• reduce the requests for pain medication and epidurals, as well as the incidence of cesareans

Penny Simkin, another DONA founder, childbirth educator, and birth counselor, found in her research that a woman's recollection of her birth experience is one that generally does not fade with time.  Simkin was shocked that women could remember their births with such great detail and accuracy years later.
The birth of your baby is an experience that you want to be as positive an experience as possible.  Proper preparation for birth and continuous support throughout the process is key to ensuring that the birth be a satisfactory memory.  
So, you may be thinking that your care provider or the hospital nursing staff will be able to give you all the support you need.  True, they will be able to support you through your clinical and medical needs throughout the labor and birth experience.  However, so much of labor and birth goes beyond the medical requirements.  It is also the case that most of the time, your care provider and the nursing staff will have other patients in the midst of labor as you are and will not be able to devote undivided attention to your needs.  This doesn't mean that they would not love to be able to, but the nature of their work requires that they provide the clinical and medical services to multiple women simultaneously.  Some women and their partners are surprised by the amount of time they spend on their own in the laboring room.
Another thought women often have is, what about my partner?  Can't they be my support?  They should be my support, right?  Yes, that too is true.  Mothers should choose those significant others, family, and friends that they wish to be present for them throughout the birth process.  There is nothing that can take the place of the support of these people for the laboring woman.  Not even a doula.  However, a doula is a different sort of support person in birth.  Doulas are highly trained professionals who are familiar with the unique needs and requirements of the laboring/birthing woman.  Doulas have skills that they have worked hard to learn that they can use at various points throughout labor and in more complicated situations to help ease a woman's fears and discomforts.  Doulas can also help the other support people better support the laboring mother through sharing techniques and offering suggestions.
The goal of providing doula services with Birth True is to provide any woman who desires this support the opportunity to have it.  As I mentioned previously, Heather and I do our best to make this possible for any mother who calls us and truly desires the benefits of having a doula at her birth.  We could not find the strength to give our time and efforts to this sort of work (both of us being mothers ourselves) if we did not feel like it was a necessary part of healthy pregnancy, labor, and birth regardless of how the woman plans or needs to birth.  Doulas are necessary in both med-free and medicated birth.  They are necessary in both vaginal and surgical birth.  They are truly an asset to any mother who places a value on a doulas presence in her labor room.
If you would like to talk more about what a doula can do for you, feel free to comment here, use the contact form on this site, or email us at info@birthtrue.com.  Have you experienced the support of a doula?  Please, share that experience with us as well.