The Great Birthing Partner Debate.......

Dublin Hospital's refusal of Additional Birthing Partners and Doulas.

“Every woman deserves to have her mother in the delivery room with her” I remember reading these words on rollercoaster.ie years ago from a young scared Irish woman due with her first baby. Her heartfelt plea for help…her desperation for ANY suggestion ….of ANY possible way that she could persuade her maternity hospital to make the exception to the rule and allow her mother and husband in with her for the labour and birth. Likewise I remember the replies of other women…women who have gone through it before…women who dripped with cynicism because they too would have liked this choice but knew what her outcome would be. The pain, confusion and fear of that sad, sad post have stayed with me over the years.

Unfortunately it looks like very little has changed for women in some areas of Ireland . While many maternity units around the country are receptive of additional birthing partners and Doulas, the Dublin hospitals remain unresponsive.

AIMS Ireland has decided to look deeper into this issue.

BACKGROUND INFORMATION

Female birthing partners

The desire to have our mothers, sisters or female friends with us in labour is a primal and instinctual example of women’s abilities to act on intuition. For centuries women have given birth with the support and understanding of elder women who have the life experience to guide the labouring woman through her birth. It makes absolute sense that women would chose to labour with their mother or sister in addition to their husband or partner. Women are naturally empathetic, supportive and strong.

Research has shown that the use of an additional birthing partner or Doulas is extremely beneficial for the labouring woman. According to some research, midwives and nurses only are able to give 10% of their time in ‘supportive roles’ in labour and birth. It is not surprising then that women feel the need to find additional emotional support either in a family member, friend or through hiring a Doula.

Research has found that women who laboured and birthed with a female partner showed extensive benefits to those who did not. Women had more spontaneous vaginal deliveries (91% to 71%), less analgesia use during labor (53% to 73%), less oxytocin (13% to 30%), fewer amniotomies to augment labor (30% to 54%), fewer vacuum extractions (4% to 16%) and fewer cesarean sections (6% to 13%) compared to the control group. The support of a female relative while in labor is shown to have fewer interventions and increased frequency of normal vaginal deliveries. (1)

Similar findings show that the use of a professional Doulas also highly beneficial for labouring women.

What’s a Doula?

Doula (Greek) is a woman experienced in childbirth who provides continuous emotional support to the labouring mother and her partner. A Doula’s primary role is to the mother. Their sole focus is on the emotional well-being of the woman in labour. Unlike a midwife who may be assigned several labouring women and whose focus in on physiological/medical birth issues, the Doula’s primary focus is on one woman and is undivided emotional support. This support is reflected in the Doula ideology and Doula promises.

Research has shown that due to the individual emotional support provided that women labouring with a Doula may prosper from a range of benefits.

Evidenced Based Benefits

Research showed:
· women using a Doula have a 50% reduction rate in cesarean section
· women using a Doula have a 40% reduction in the rate of forceps deliveries
· women using a Doula have a 60% reduction in request for the epidural
· women who used a Doula had a decrease in labour length by 25% (2)

CLOSER TO HOME

Doula Association of Ireland – face to face

With all the talk of Doulas and hospital policy it became apparent that there is a lack of understanding with hospital administration and some members of the public as to what a Doula’s role is in Ireland. To gain greater insight I recently attended a Doula training seminar and interviewed several Doulas working in Ireland .

Doulas in Ireland work independently or with the support of an organisation called The Doula Association of Ireland. The Doula Association of Ireland is a voluntary organization founded in March of 2006. The Association follows a Constitution mirroring ethics from DONA (an international and highly respected Doula Association) and is run by an elective committee. The Doula Association is a self-regulating professional support network for Doulas working in Ireland .

From meeting with the Doulas it was clear that there is a great need for additional support when giving birth in Ireland . As a Doula is not providing clinical care her role is not diluted. She is a comforting and supportive continuous presence for the labouring woman which benefits midwives who are often over stretched in Ireland ’s maternity units. “Our midwives are under tremendous pressure. Midwives are trying to provide both clinical care and emotional support in labour – sometimes to more than one woman,” describes one of the Doulas. Another adds, “Also…midwives take lunch breaks, they go home when their shift ends. As Doulas our support is continuous for the labour and birth…this is extremely important to most women.”

A Doula does not replace the partner but rather encourages the partner to be as involved as his comfort level allows. As one mum describes, “My husband wasn’t initially sure about using a Doula but on the day he found it a great relief to have her there. It meant he could go through this with me – he could have his own experience knowing that my Doula would provide all the emotional support I needed. It took the pressure off of him - he was really worried about how he would perform on the day.”

As an outsider with little experience of Doulas, the Doula training was simply inspiring. Listening to the principals and stories from these enthusiastic women truly brought home the degree in which we are failing women in our sterile maternity units. The room buzzed with hope, emotion, empathy, support, and sadness over the stories we heard about birth in modern Ireland . There was an overwhelming sense of normality in the stories we heard relating to Doula births – it struck me as ironic that in the attempt to promote ‘normal’ birth in Ireland , many hospitals were purposely opposing a fundamental normal birth practice. From the short time I spent in the Doula training I came away with a real sense of hope and inner calm…a feeling of relief that these new recruits would make some woman’s experience that much more manageable as she will have the extra support of her Doula. In my final moments in the training the DONA instructors explained an overview of the principals which encapsulate the level of emotional care that Doulas offer. These are called the Doula Promises.

Promises of a Doula

1. You cannot hurt my feelings in labour
2. I won’t lie to you in labour
3. I will do everything in my power so you do not suffer
4. I will help you feel safe
5. I cannot speak for you but I will make sure that you have a voice and I will make sure you are heard

Ireland is continuously training Doulas and most of Ireland ’s maternity units have open policy of acceptance of Doulas. Unfortunately, due to hospital policies, women in the Dublin area who wish to have a Doula must attend Our Lady of Lourdes, Drogheda (which has an open acceptance of Doulas) as the Dublin hospitals no longer are permitting women to exercise this choice.

Hospital policy

The issue of Doulas and additional birthing partners has a tempestuous history in Ireland ’s maternity hospitals – Dublin in particular. The policy used to stand that women who desired the use of an additional birthing partner could alternate between the two as she needed them in labour. Not an ideal situation, but better than the alternative. However, recently the decision was taken by the Dublin hospitals to re-evaluate their policy on Doulas and alternating birth partners. New policy states that women are no longer ‘allowed’ the use of alternating birthing partners and that Doulas may only attend as a birthing partner (not “allowed” to call themselves a Doula). To further illustrate their policy, it was decided that there would be a full ban on the word ‘Doula’ in the magazine sponsored by the 3 Dublin Hospitals and a ban on any advertising within the magazine by Doulas. Sadly, it appears that hospital ‘policy’ has outweighed women’s desires once again.

It is a great concern of AIMS Ireland that given the current wording and restrictions in the Dublin hospitals (No swapping in and our of birthing partners, no additional birthing partners, no Doulas), specifically in the concise policies of the Rotunda and National Maternity Hospital, the policy concerning Birthing Partners and Doulas leaves very little room for compromise in times of unusual or ‘special’ circumstances. AIMS Ireland ’s concern is with the mother in cases such as this. Our worry is that should a woman’s designated birthing partner be called away for any reason or becomes unable to provide support (children at home, illness, etc) that the labouring woman will be especially vulnerable without the emotional support and continuity of a birthing partner. For many women the fear of labouring ‘alone’ (without a birthing partner or loved one) is extremely concerning and will induce intense feelings of panic and stress at a time when the mother should be kept focused and relaxed. Unfortunately, the reality of modern birth means that the midwife cannot provide this continuity of care and emotional support – hence the importance of the birthing partner or Doula. Another issue to consider is women who are transferring to hospital from a homebirth. Women in this situation have built a relationship with their independent midwife over the period of 9 months. The woman will already be emotionally distressed at the prospect of having to transfer to a hospital scenario for her birth and policy of only one birth partner (partner or independent midwife) will add to her distress. The Rotunda and NMH have each provided statements that in extremely ‘special circumstances’ the birthing partner policy would be re-visited, however, it is the decision of the hospital to determine what constitutes a ‘special circumstance’….not the woman. AIMS Ireland believes that all labouring women and all labouring women’s circumstances are ‘special’.

Who’s needs are most important?

Who’s needs are the most important? …. This is the question.
AIMS Ireland is fully supportive of the CIMS Mother-friendly initiative. One of the main principals of this initiative is that women are the centre of the maternity system….she is the leader of her birth team. Not hospital staff. Not consultants. Not midwives. Not Doulas or birthing partners. The mother knows what support she needs in labour and her care should be centred on her choices to do so in a safe and encouraging manner. Women’s choices should be met with respect and dignity. Women should never be fobbed off by a mantra of what is “allowed”. This is after all, HER and HER baby’s experience. With Dublin ’s current birthing partner and Doula policy in place, these hospitals are quite simply NOT mother-friendly hospitals. It is with absolute arrogance that hospital administration believes they can write policies to exclude evidence based birthing choices from women. Current hospital policy is wrongly based on the hospital administration’s assumption that they can provide everything a woman needs. The Doula and birthing partner policy is a reflection on hospital administrations lack of concern for the mother’s true non-medical needs – of continuity of support and emotional care. Quite simply, our Dublin hospitals have failed in remembering that women’s needs come first.

So why are Irish Hospitals so reluctant to allow women the freedom of choice in birthing partners?

AIMS Ireland is at a loss to answer this question and explanations from the hospitals are watery at best!

The benefits of additional birthing partners and Doulas are evidence based something for which Irish hospitals claim credit. The Coalition for Improvements in the Maternity Services (CIMS), which is evidence based UN backed organization, has included the woman’s right to choose additional birth partners and use of Doulas in its conditions for a hospital or maternity unit to gain ‘Mother-Friendly’ status. It is recognized worldwide the benefits and emotional importance for women to not be restricted in their choice for birthing partners. Yet, time and time again, women come up against the proverbial brick wall of ‘hospital policy’ when trying to exercise this very basic maternal right.

It has been suggested with Irish Hospitals that policy of one birth partner is in relation to risk of infection; MRSA. Yet research has shown that an additional birthing partner has no effect on the spread of infectious illnesses. Birthing partners do not create and spread infection…dirty hospitals do.

The Doula Association of Ireland has applied for Garda vetting but unfortunately as Doulas do not have unsupervised access to children or vulnerable adults they are low down on a long list of priorities. As Doulas are not registered with the Gardai, hospital administration has suggested that there is an increased security risk with the use of Doulas. Doulas possess no added security risk than any other birthing partner. Despite this fact, The Doula Association of Ireland recommends that all Doulas give advanced notice of their intentions on attending a birth at a hospital out of common professional courtesy and for security reasons. When AIMS Ireland looked further into this issue we found that the Doula Association of Ireland has offered on several occasions for a registration process to be set up within the hospital and each time the hospital administrations failed to engage in consultation to implement such changes. To date, representatives from the Doula Association of Ireland have been denied a face to face meeting with hospital personnel to discuss this matter further. Some individual Doulas have offered to be fingerprinted and to have background checks in order to assist with hospital security queries. We have also learned that despite failing negotiations with hospital administrators, the Doula Association of Ireland has voluntarily presented the Rotunda hospital a full detailed list of all registered members of the Doula Association of Ireland in order to assist in security maintenance. In conjunction, The Doula Association of Ireland has created a regimented Constitution and grievance procedure in which all Doulas registered with the DAI must adhere to….. But again, the Dublin hospitals were not interested.

Summery

So the question is what are the REAL reasons why Dublin ’s Maternity Hospitals have shut the door to Doulas and additional birthing partners? One can only hazard a guess…..

Fear? ………Distrust? ………Unwilling to have an independent observer present?...Lack of education and understanding on the role of a Doula?

Truth be told, it doesn’t matter. All these ‘issues’ are simply a smokescreen in which the Dublin hospitals deter this debate from the core issue. Quite simply, Dublin hospitals are unwilling for consumers to have input on hospital policy.

The true bones of this matter are that every woman has the right to choose who comes in with her for the labour and birth of her baby. It has nothing to do with the hospital or its rules. Women-centred care means that women as consumers lead the hospital in policy relating to the care they receive.

According to the An Bord Altranai’s website, The Philosophy of Midwifery includes:

A) The focus of midwifery practice is pregnant women and their families and delivering women-centred maternity services.
B) Decisions about an individual midwives scope of practice should always be made with the woman’s and her family’s best interest foremost and in the interest of promoting and maintaining the best quality maternity services for women.

Quite simply, why are Irish women paying the salary of maternity staff when they have no say in the type of treatment they want?

The use of additional birthing partners and Doulas is a regular and normal occurrence in the US , UK , Australia , France , Singapore , and elsewhere within our own country of Ireland ( Cork , Drogheda , Etc). AIMS Ireland ’s final thoughts on this are that if Dublin hospitals are truly serious in promoting normal birth and normal birth practices then they must abolish this policy and embrace mother-friendly practices in their entirety. At present with current Doula and additional birthing partner restrictions in place it is a case of talking the talk without delivering on core issues.

References:

1. Madi, B.C., Sandall, J., Bennett, R., & MacLeod, C. (1999). Effects of female relative support in labor: A randomized controlled trial. Birth, 26 (1), 4.8.

2. John H Kennell, MD; PEDIATRICS Vol. 114 No. 5 November 2004, pp. 1488-1491 (doi:10.1542/peds.2004-1721R)

Resources and Information:

http://www.motherfriendly.org/resources/10Q/

http://www.motherfriendly.org/MFCI/references/1CIMSAcce...#Madi

http://pediatrics.aappublications.org/cgi/content/full/.../1488

http://www.dona.org/

http://www.doulaassociationofireland.com/

http://www.doulaireland.com/

http://www.dohc.ie/agencies/1.html