A Different Perspective on What Doulas Actually Do
In honor of International Doula Month, I feel compelled as I often do each year to write a blog post both celebrating the work I do alongside many other birth workers, as well as promoting awareness of this truly crucial vocational field. But before I tell you about what I AM going to discuss, I should tell you what I’m NOT going to discuss.
I’m not going to discuss the many clinical studies showing that continuous labor support improves clinical outcomes like reducing cesarean rates, requests for pain medication and length of labor. I’m also not going to discuss the recent statements by leading medical experts supporting the importance of the doula role. Why? First, because it’s already been done. Just Google “evidence for doula support” and you’ll find lots of amazing information.
Secondly, I believe when we look at clinical outcomes, we’re just getting a little off track. So, I’d like to celebrate International Doula Month by shining some light on what doulas actually do, and more importantly HOW they do it.
What do I do as a doula? I show up and I bring my heart. Read on to see what I mean by that!
Clinical Outcomes: Important but Not the Focus
It’s really important to clarify that doulas are not clinical or medical professionals. While some professional doulas may have clinical expertise, the generally accepted scope of practice of a doula indicates he or she does not perform clinical tasks while operating in the doula role, but instead offers physical, emotional and informational support to the birthing person .
Clinical outcomes are not the doula’s focus, or at least they shouldn’t be. One of the earliest studies that led to the formalization of the doula role wasn’t even focused on continual support or birthing outcomes. In the study by Kennel and Klaus focused on mother-infant bonding, researchers unintentionally discovered the continuous presence of the observer (who was there to document skin-to-skin contact) correlated with improved birthing outcomes . These were not even trained labor support persons, yet their caring communication and continuous contact with parents impacted outcomes positively!
Dr. John Kennel describes that early study,
“Once again, a carefully designed protocol was disregarded, to the dismay of the researchers. The medical students had been told that they had to do things according to hospital rules and to not interfere. This meant that the researchers must not be involved with any mother until after delivery, [and] even then, they should not go into the room or talk with the mother.
“One of the students, Karen Wendy Freed, did not follow protocol. Once a mother was admitted into the bonding study, she felt she shouldn’t leave the mother alone. She would go in and talk with them, and would stay there…When Wendy discussed the first 10 babies after joining the study, she acknowledged to Dr. Klaus that the mothers were very calm and peaceful. It seemed as though a number of things were better for these mothers… The positive outcome of the babies was striking, but we didn’t know if it was a fluke. Very often, when you see something different that you think is going to be marvelous, there is a simple explanation that does not give you valuable new information. Therefore, we proceeded to design a new study for confirmation”
In fact, in a study of long-term birth satisfaction, Penny Simkin, PT found that clinical features of birth aren’t typically a major focus of mothers either! She stated,
“I found that if particular factors were present, women are more likely to feel long-term satisfaction [with their births]. These factors have more to do with the way they conduct themselves and the way they were treated than with the actual clinical features of their labor” 
In all honesty, it can be difficult for doulas themselves to adequately explain what exactly we do and why there even is a correlation with doula support and improved clinical outcomes. The studies and evidence are there and no one’s refuting them. Doulas most certainly contribute to improved maternal and fetal outcomes substantially. But the question is HOW?
In her keynote presentation at the 2016 Doula International Engage Conference, Simkin asked, “If doulas have the least amount of medical training, how do they have such strong impact on clinical outcomes?”
She then went on to make one of the clearest, powerful and yet incredibly simple explanations for the impact doulas have on the childbirth experience. It confirmed what experienced doulas know deeply to be true, but don’t always have the vocabulary to describe. She argued that it's the unique way doulas communicate that sets them apart.
The Doula’s Unique Method of Communication
Unfortunately, there really is no such thing as magic doula fairy dust, although it can really seem like it if you don’t understand what’s happening below the surface of the birthing experience.
Simkin believes the way doulas communicate with clients makes the most impact. Labor causes an altered state of consciousness (reduced or chaotic activity in the neocortex), which contributes to:
- Fight or Flight state (intense negative emotions)
- Reduced Awareness of Surroundings/People
Let’s look at the difference between the medical caregiver’s mode of communication verses the doula.
Speaks to & from neocortex
Left-brained, one way communication, rational explanations
- Difficult for client to communicate here because of altered conscious state
- Can cause trauma with communication by failure to understand altered state
- Communicates via autonomic nervous system & limbic system (touch, soft voice)
- Aware of client’s altered state & attunes to client
- Displays empathy, acknowledges difficulty, gives simple instructions
- Aids client in using neocortex as needed 
If one has even a basic understanding of how the brain functions during childbirth and the impact of the hormones in relation to brain function, it’s easier to understand that by engaging a laboring person in a sensitive, calm, respectful manner and meeting them where they are, a doula can support the physiologic flow of labor. In this way the normal birth process is encouraged, thus minimizing the need for interventions to address any problems (because fewer problems arise). It’s not magic, but it IS miraculous, as the fascinating process of childbirth intrinsically is.
So, how exactly does a doula engage with a laboring person in the vulnerable and altered emotional state or “meet them where they are?”
Implications of Emotional Support & Empathy
The vast majority of doula training and continuing education revolves around the physical and informational support roles, such as knowledge about interventions and options or techniques for comfort measures and labor progress. While the emphasis on the emotional support role is increasing, it is still difficult to find substantial and concrete evidence or training on the topic within the mainstream world of birth work. Personally, I have found more emotional intelligence tools in other self-help and personal growth arenas as I pursue my own emotional well being, but I’m excited about integrating it into my work influencing birth workers and parents alike.
Amy Gilliland, Ph.D., DONA Approved Doula Trainer, CD(DONA), AASECT Certified Sexuality Educator writes in her study, After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada,
“Emotional support for laboring mothers is considered one of the main functions of birth doulas…Methods of emotional support are “complex, requiring experience at numerous births, reflection, a clear understanding of the mother's needs, & ultimately a deepening level of emotional intelligence & skill”.
A study of empathy is an excellent path to understanding how to engage in “emotional support,” and Brené Brown is one of the leading experts in the field of study on vulnerability, shame and empathy. She also is truly gifted in explaining her scientific research in an accessible way. In order to access empathy, we essentially have to intentionally access emotions in a very brave manner. She explains in The Power of Vulnerability,
“The problem is--and I learned this from the research--that you cannot selectively numb emotion. You can't say, here's the bad stuff, vulnerability, grief, shame, fear, disappointment… I don't want to feel these. You can't numb those hard feelings without numbing the other affects, our emotions. You cannot selectively numb. So when we numb those, we numb joy, we numb gratitude, we numb happiness.” 
What she’s saying is that if we want to engage positive emotions, we must also expose ourselves to negative ones, resisting our natural inclination to protect ourselves and cultivate an acceptance and comfort level with our own (and I would add others’) discomfort. This skill is crucial as a doula entering the intimate, vulnerable and often fear-filled space of childbirth. Brown goes on to say, “Empathy is a choice, and it’s a vulnerable choice. In order to connect with you, I have to connect with something in myself that knows that feeling” .
THIS is what a doula does. I don’t know who coined the term, but I have heard many say a good doula is much more of a “be-la” than a "do-ula," meaning the ability to be present, listen, acknowledge the raw emotions of the laboring person and give the type of support desired without attempting to influence the situation to meet their individual agenda, but rather that of the client. Ed Batista from Harvard Business Review states,
“A leader who can leverage this dynamic effectively has a tremendous competitive advantage. They can acknowledge negative emotions (both their own and others) and manage or make use of them in a way that's healthy and productive, rather than A) seeking to repress or ignore them or B) letting them spiral out of control. And they can also more fully sense and express positive emotions (both their own and others), which can be a powerful source of influence and motivation” 
This leads me to the nebulous and often misunderstood notion of “holding space.”
Holding Space: Heart Science or Hoax?
It won’t take long if you are looking for a doula for your birth or in researching doula support to come across the term “holding space.” Well-meaning individuals advocating for concrete support and scientific evidence criticize this concept or may describe it as “woo” or “hippie nonsense,” but in the desire for tangible truths, they may be ignoring scientifically provable information that is also intangible or unavailable for us to observe on a surface level.
It’s not a new concept that the physical presence of an observer or the act of observing something changes the outcome. Scientists have been studying this since the 1800s. I won’t get too detailed here (because quantum mechanics y'all), but to boil it down, scientists found when observing light patterns, any attempt to observe or detect the behavior of the waves and particles that make up light actually changed its behavior.
Emerging research on heart science lends even more credibility to the holding space concept, describing what actually occurs energetically when people occupy the same physical space.
“Evidence now supports the perspective that a subtle yet influential electromagnetic or “energetic” communication system operates just below our conscious level of awareness.
“Several studies have investigated different types of physiological synchronization or entrainment between individuals during empathetic moments or between clinician and patient during therapeutic sessions…If the heart rate of one went up, so did the heart rate of the other; if the heart rate slowed, so did that of the empathic spouse.
“The nervous system acts as an antenna, which is tuned to and responds to the magnetic fields produced by the hearts of other individuals. My colleagues and I call this energetic information exchange cardioelectromagnetic communication and believe it to be an innate ability that heightens awareness and mediates important aspects of true empathy and sensitivity to others. Furthermore, we have observed that this energetic communication ability can be enhanced, resulting in a much deeper level of nonverbal communication, understanding, and connection between people. We also propose that this type of energetic communication between individuals may play a role in therapeutic interactions between clinicians and patients that has the potential to promote the healing process” 
Celebrating and Supporting What Doulas Really Do
Every day I learn more about my work and how to do it better, and as a childbirth educator and trainer for doulas, I’m passionate about knowing this work inside and out and doing my part to equip other professionals with the knowledge I find. This information has fueled the YBE Equip program and I’m loving hearing the feedback from the doulas in it. If you’re a doula and want to try this program, click here and use code “DOULAMONTH10” to get the course for 10% off for the remainder of International Doula Month!
Written by Missy David, BS, CD(DONA), CYBET, CLC, HCHD
1. Doula. (n.d.). Retrieved May 18, 2017, from https://www.merriam-webster.com/dictionary/doula
2. Klaus M, Kennell J. Maternal-infant bonding. St.Louis: The C.V Mosby Company; 1976
3. Olness, K., Myers, C., with Hellerstein, M. (2015). Keep mothers and babies together: The story of Dr. John Kennell. Amarillo, TX: Praeclarus Press.
4. Simkin, P. (1991), Just Another Day in a Woman's Life? Women's Long-Term Perceptions of Their First Birth Experience. Part I. Birth, 18: 203–210. doi:10.1111/j.1523-536X.1991.tb00103.x
5. Penny Simkin, PT, BDT(DONA) (2016, July). The Year of the Doula. General Session presented at the DONA International Engage Conference in Bellvue, WA.
6. Gilliland, A. L. (2011). After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada. Midwifery, 27(4), 525-531.
7. Brown, Brené. “The Power of Vulnerability: Teachings on Authenticity, Connection, and Courage. Sounds True, 2012.
8. Batista, E. (n.d.). Brené Brown, Vulnerability, Empathy and Leadership. Retrieved from http://www.edbatista.com/2014/08/brene-brown-vulnerability-empathy-and-leadership.html
9. McCraty, R., Ph.D. (2003). Boulder Creek, CA: Institute of Health.