Response to the Consejo General de Enfermería (General Nursing Council, Spain) ‘Dossier de prensa – La verdad sobre las doulas’.
The European Doula Network (EDN) is a non-profit umbrella organisation with a membership of over 30 Doula associations and training courses organisations across 19 different countries. The network supports doulas across Europe in establishing formal, accountable organisations in their countries and shares an ethical philosophy on the role and boundaries of a doula as a non-medical support person for women and families in the childbearing year.
The EDN is astounded to learn about the ‘Informe Doulas’ Report and website from the Consejo General de Enfermería (General Nursing Council) in Spain. The Report and website contain slanderous allegations regarding doulas engaging in harmful activities. The report links doulas to issues that are clearly outside of the doula scope of practice without providing any real evidence.
We are shocked and saddened to see that the Council did not consult any Spanish Doulas Organisations, or the parents and the medical professionals who have been working with doulas for several years now, in preparing this report. Neither did they examine the medical evidence and publications available from international studies going back over decades.
Doulas: evidence based support for women and families
Doulas provide continuous emotional and practical support, for mothers and couples, through pregnancy, birth and immediately postpartum, also providing flexible practical and emotional support postnatally for new mothers and families in their own homes. Doulas are usually experienced women and mothers who have undertaken a doula preparation course.
Doulas support women and families from all ethnic, religious, social backgrounds, including couples and single parents, same sex parents, low income families and executives, students, lawyers, midwives and doctors etc.
Doulas spend time building a relationship with the families they are supporting. They offer space and time for parents to discuss and reflect upon their own situation, their needs, past experiences and options in childbirth to enable them to move towards a positive experience. Doulas are not there to take the place of a father-to-be or partner during a birth, unless parental choice, circumstances or cultural pressures mean that the mother’s partner is unable to be with her during labour and birth.
Doulas do not take a clinical role, they work alongside their client’s care providers, supporting clients in their own choices. At all times a doula is led only by her client’s wishes and does not make specific recommendations, though may signpost to evidence-based resources and information.
The evidence from research (Hodnett et al. 2013. Brigstocke S, 2014. Goldbort J, 2002) is that support from a doula can mean:
Reduced risk of Caesarean birth.
Reduced risk of instrumental birth.
Reduced need for painkillers or epidural during birth.
Reduced rate of induction of labour.
Increased satisfaction with women’s experience of birth.
Increased likelihood of initiating breastfeeding.
Reduced risk of, or severity of, postnatal depression.
Increased likelihood of successfully establishing breastfeeding and breastfeeding at 6 weeks.
Furthermore, the 2013 Cochrane Review on continuous support for women during childbirth concluded that:
“all women should have continuous support during labour. Continuous support from a person who is present solely to provide support, is not a member of the woman’s social network, is experienced in providing labour support, and has at least a modest amount of training [i.e. a doula], appears to be most beneficial.” (Hodnett et al, 2013)
The 2012 commentary by The World Health Organization Reproductive Health Library ‘Continuous support for women during childbirth’ states:
“Considering all the advantages and possible lower costs to the health system associated with the presence of a doula (less likelihood of cesareans sections and analgesia use), covering the cost of doula services should be considered by policy-makers.”
In the UK, doulas are an accepted part of maternity services. Some National Health Service (NHS) hospitals employ doulas and other have doulas as authorised volunteers, coming onto wards to support new mothers. Doula UK (founded in 2001 and the main organisation for UK doulas) has regular meetings with the Royal College of Midwives (RCM) and is represented at Parliamentary Group meetings. Doula UK and some charities provide a free service of support for vulnerable women in the UK. In Poland, doulas are “regulated” and recognised by the government since January 2015, with the Doula in Poland Association being registered in the National Court Register as a Non-Governmental Organisation (NGO) created to unite and educate doulas.
In the USA, DONA International, the world’s oldest and largest organisation of doulas, was founded in 1992 by a small group of some of the foremost experts in childbirth. DONA International now has over 7000 members around the world.
Around Europe, laws, policies and practices vary that affect a woman’s ability to choose where she gives birth, with which medical attendants (or none) and with whom to support her. In France, a doula can be at a birth at home only if a midwife or doctor is present and in other countries, birthing at home with midwives may not be possible. In contrast in the UK, women have the legal right to birth at home if they wish, either with midwives or unattended, whether or not a doula (who is not a medical attendant) is present. In The Netherlands and some European countries, it is standard to allow at least 2 birth partners for a woman in labour, whereas other countries, including Spain and Poland, often make a woman choose only 1 birth partner. Sadly some public hospitals in Turkey will not allow anyone to support the birthing woman.
The 2013 Cochrane Review stated that “in many countries… continuous support during labour has become the exception rather than the norm. This may contribute to the dehumanisation of women’s childbirth experiences. Modern obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour.” (Hodnett et al, 2013)
The European Convention on Human Rights offers protection to all individuals making choices in childbirth. In recent cases the courts have asserted that Article 8 of the convention protects a woman’s right to decide the circumstances and location in which they give birth. Women should never have any medical procedure performed without consent, should be able to decline unwanted interventions however minor they may seem to staff and should always be provided with sufficient, objective and unbiased information to make an informed choice. In extreme cases disrespectful treatment during childbirth may also violate Article 3 of the convention which relates to cruel, inhuman or degrading treatment.
Concerns about restrictive or non-evidence based policies, and adverse outcomes, may cause women to choose a birth place and situation that is out of the norm for their locality.
The EDN are calling on the Consejo General de Enfermería of Spain to rescind their ‘Informe Doulas’ report, and remove the website, immediately, and conduct a proper consultation, including a balanced consideration of all the evidence, before producing a replacement. The EDN would be very happy to participate in such as a consultation.
The EDN will be supporting the Spanish EDN members to seek legal guidance regarding steps to take in response to what we believe to be libellous statements contained in the report and on the ‘Informe Doulas’ website.
The European Doula Network.
26th February 2015
Additional Information & References
The European Doula Network (EDN)
The European Doula Network (EDN) was created in 2011. It is a non-profit umbrella organisation with a membership of over 30 Doula associations and training courses organisations across 19 different countries.
The network supports doulas across Europe in establishing formal, accountable organisations in their countries and shares an ethical philosophy on the role and boundaries of a doula as a non-medical support person for women and families in the childbearing year.
Doulas in the UK, a charitable purpose
In the UK, there are organisations, such as Birth Companions and the Doula UK Access Fund, which enable vulnerable women, such as those who are, have been or are at risk of being detained, those in a domestic abuse refuge, refugees or those in financial hardship, to access doula support for free. In some areas, doulas are also employed by the National Health Service (NHS).
BirthRights. Human Rights in Maternity Care. 2013. http://www.birthrights.org.uk/library/factsheets/Human-Rights-in-Maternity-Care.pdf [Accessed 18 February 2015]
Brigstocke S. MIDIRS Midwifery Digest, vol 24 no. 2, 2014, pp 157-160
Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5 2008
Female relatives or friends trained as labor doulas: outcomes at 6 to 8 weeks postpartum
Campbell D, Scott KD, Klaus MH, Falk M – Graduate Division, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.
Amorim MMR and Katz L. Continuous support for women during childbirth: RHL commentary (last revised: 1 May 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.
Continuous support for women during childbirth
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C – Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 2, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
Doctors and doulas in the labor and delivery suite –
Kuczkowski KM, Acta Anaesthesiol Scand. 2007 Aug;51(7):954-5.
Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’ wellbeing in a Mexican public hospital: a randomised clinical trial
Langer A, Campero L, Garcia C, Reynoso S – The Population Council, Regional Office for Latin America and the Caribbean, Colonia Coyoacán, México DF, Mexico.
A randomized control trial of continuous support in labor by a lay doula
Study on Sleep & Functional Performance in Heart Failure at the University of Medicine and Dentistry of New Jersey, School of Nursing, Newark 07101-1709, and Division of Maternal Fetal Medicine, Saint Peter’s University Hospital, New Brunswick, NJ, USA.
Nurses and doulas: complementary roles to provide optimal maternity care
Ballen LE, Fulcher AJ, J Obstet Gynecol Neonatal Nurs. 2006. Mar-Apr; 35 (2) : 304-11.
On Labor support and doulas
Buck L, AWHONN Lifelines. 2006 Aug-Sep; 10 (4): 279-280.
They call them “doulas” or “birth attendants
Halle L, Baddour C, Rev Infirm. 2006 Jun-Jul; (122): 39 (français).
Doulas as Community Health Workers: Lessons Learned from a Volunteer Program
Kane Low L, Moffat A, Brennan P, J Perinat Educ. 2006 Summer;15(3):25-33.
Use of a doula for labor coacing in a patient with indolent mastocytosis in pregnancy
Kehoe SL, Bathgate SL, Macri CJ, Obstet Gynecol. 2006 feb; 107 (2 Pt 2) : 514-516.
Doula Support and Attitudes of Intrapartum Nurses: A qualitative Study from the Patient’s Perspective
Papagni K, Buckner E, J Perinat Educ. 2006 Winter; 15 (1): 11-8.
Perceptions of social support from pregnant and parenting teens using community-based doulas
Breedlove G, J Perinat Educ. 2005 Summer; 14 (3): 15-22.
Evidence on support during labor and delivery: a literature review
Bruggeman OM, Parpinelli MA, Osis MJ., Cad Saude Publica. 2005 Sep-Oct; 21 (5):1316-27. Epub 2005 Sep 12 Review. (Portugais)
Doulas a childbirth paraporfessionals: results from a national survey
Lantez PM, Low LK, Varkey S, Watson RL Womens Health Issues. 2005 May-June; 15 (3):109-16.
Sustaining rural maternity care – don’t forget the RNs
Medves JM, Davies BL, Can J Rural Med. 2005 Winter; 10 (1): 29-35.
Doula birth support for incarcerated pregnant women
Schroeder C, Bell J, Public Health Nurs. 2005 Jan-Feb; 22 (1): 53-8.
Lower epidural anesthesia use associated with labor support by student nurse doulas: implications for intrapartal nursing practise
Van Zandt SE, Edwards L, Jordan ET, Complement Ther Clin Pract. 2005 Aug; 11 (3): 153-60
Doulas are necessary!
Waldenstrom U, Lakartidningen. 2005 Jan 24-30; 102: 221-2. Swedish
Childbirth Educators, Doulas, Nurses, and Women Respond to the Six care Practices for Normal Birth
Curl M, Davies R, Lothian S, Pascali-Bonaro D, Scaer RM, Walsh A, J perinat Educ. 2004 Spring; 13 (2): 42-50.
Doulas are helpful, but they’re not nurses
Phillips E, RN. 2004 Jul; 67 (7):12.
Do maternity care provider groups have different attitudes towards birth?
Reime B, Klein MC, Kelly A, Duxbury N, Saxell L, Liston R, Prompers FJ, Entjes RS, Wong V, BJOG. 2004 Dec; 111 (12): 1388-93.
Position statement 6: doulas
Royal College of Midwives, 2004 sep; 7 (9): suppl 1.
Continuity of caregivers for care during pregnancy and childbirth (2003)
Hodnett, E.D. (2003) The Cochrane Library, Issue 3, 2003. Oxford: Update Software.
Childbirth Education and Doulas Care During Time of stress, Trauma and Grieving
Pascali-Bonaro D, J Perinat Educ. 2003 Fall; 12 (4); 1-7.
Postpartum depression: Bridging the gap between medicalized birth and social support (2002)
Goldbort, J. (2002) International Journal of Childbirth Education Vol 17(4):11-17.
Beyond holding hands: the modern role of the professional doula
Gilliland AL, J Obstet Gynecol Neonatal Nurs. 2002 Nov-Dec; 31 (6): 762-9.
Doulas: an alternative yet complementary addition to care during childbirth
Kayne MA, Greulich MB, Albers LL, Clin Obstet Gynecol. 2001 Dec 44 (4): 692-703.
Doulas supporting women during labor: the experience at the Sofia Feldeman Hospital
Leao MR, Bastos MA, Rev Lat Am Enfermagem.2001 May; 9 (3): 90-4. (Portugais)
Benefits of massage therapy and use of a doula during labor and childbirth (2000)
Keenan P. Altern Ther Health Med 2000 Jan;6(1):66-74 Potomac Massage Training Institute, USA.
The obstetrical and postpartum benefits of continuous support during childbirth (1999)
Scott KD, Klaus PH, Klaus MH. J Womens Health Gend Based Med 1999 Dec;8(10):1257-64 Division of Public Health, County of Sonoma Department of Health Services, Santa Rosa, California 95404, USA.
Continuous emotional support during labor in a hospital Kennell JH, Klaus M, & McGrath SK, 1999 , JAMA, vol. 265, pp. 2197-2201.
A comparison of intermittent and continuous support during labor: a meta-analysis
Scott KD, Berkowitz G, Klaus M, Am Obstet Gynecol. 1999 May; 180 (5):1054-9.
Doula support vs. epidural analgesia: Impact on cesarean rates
McGrath, SK, Kennell JH, & Suresh M, 1999, Pediatric Res, vol. 45, no. 16A.
Effects of providing hospital-based doulas in health maintenance organization hospitals
Gordon NP, Walton D, McAdam E, Derman J, Gallietro G, Garrett L, Obstet Gynecol. 1999 Mar; 93 (3): 422-6.
Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’wellbeing in a Mexican public hospital: a randomised clinical trial
Langer A, Campero L, Garcia C, Reynoso S. Br J Obstet Gynaecol 1998 Oct;105(10):1056-63 The Population Council, Regional Office for Latin America and the Caribbean, Colonia Coyoacan, Mexico DF, Mexico.
The Chicago doula project: A collaborative effort in perinatal support for birthing teens
Glink P, 1998, Zero to Three, vol. 18, pp 44-50.
Doulas: exploring their roles with parents, hospitals, and nurses
Perez PG, Herrick LM, AWHONN Lifelines. 1998 Apr; 2 (2): 54-5.
First stage labor management: An examination of patterned breathing and fatigue
Pugh LC, Milligan RA, Gray S, Strickland OL Birth. 1998. Dec; 25 (4): 241-5.
Doulas: into the mainstream of maternity care
Young D, Birth. 1998 Dec; 25 (4): 213-4.
The doula: an essential ingredient of childbirth rediscovered
Klaus MH, Kennell JH, Acta Paediatr 1997 Oct; 86 (10): 1034-6.
Doulas. Aids or opportunists?
Mainord M, Tenn Nurse. 1997 Jun; 60 (3): 21.
A randomized trial of one-to-one nurse support of women in labor
Gagnon, AJ, Waghorn K, CovellC, Birth, 1997, vol 24, pp 71-77.
Supporting women in labour: the doula’s role
Nolan M Mod Midwife. 1995 Mar; 5 (3): 12-5.
Family practice maternity care in America: ruminations on reproducing an endangered species – family physicians who deliver babies Larimore WL, Reynolds JL J Am Board Fam Pract. 1994 Nov-Dec; 7 (6): 478-488.
Labor support by a doula for middle-income couples: the effect on cesarean rates
Kennell JH, & McGrath SK, 1993 , Pediatric Res., vol. 33, no. 12A.
Doulas and the quality of maternity services
Hodnett E, Birth. 1992 Sep; 19 (3): 172. Doulas and the quality of maternity services Richards MP, Birth. 1992 Mar; 19 (1): 40-1
Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding
Hofmeyr GJ, Nikodem VC, Wolman WL, Chalmers BE, Kramer T. 1991
Continuous emotional support during labor in a US hospital. A randomized controlled trial (1991)
Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. JAMA 1991 May 1;265(17):2197-201 Department of Pediatrics, Case Western Reserve University, Cleveland, OH.
A randomized trial of the effects of monitrice support during labor: mothers views two to four weeks postpartum
Hodnett ED, Osborn RW., 1989
A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates
McGrath SK, Kennell JH – Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio 44106, USA.
Effects of social support during parturition on maternal and infant morbidity.
Klaus MH, Kennell JH, Robertson SS, Sosa R.,1986
The effect of a supportive companion on perinatal problems, length of labor, and mother interaction
Sosa R, Kennell JH, & Klaus M, 1980, New England Journal of Medicine, vol. 303, pp. 597-600.