The following article can be found in the January 4th, 2007 edition of the National Post and is protected by their coypright. It is reproduced here verbatim, in the event that the National Post article link goes stale.

As more parents opt for a natural childbirth, delivery-room tension is rising between medical professionals and the doulas who are hired to provide holistic bedside support

Samantha Grice, National Post
Published: Thursday, January 04, 2007

When David and Jennifer Smith* learned they were expecting their first child, they made some decisions about how they wanted the labour and delivery to play out. Though they were determined to have a natural childbirth, they wanted to have the baby in a hospital -- so they hired a doula. They also chose not to share this last decision with hospital staff.

Doulas are women experienced in childbirth who provide non-medical emotional and physical support to women before, during and after childbirth. During labour this might mean coaching the mother with her breathing, helping with pain relief and giving reassurance. They also aspire to help the mother birth her baby naturally.

Ironically, while parents-to-be hire a doula in an effort to reduce the stress and anxiety of childbirth, adding a doula to the mix of delivery room participants has been known to create tension.

According to the Canadian Doula Association and Doula C.A.R.E. (Canadian Association Registry and Education), doula numbers have grown over the past 10 years. For the most part, parents, nurses, doctors and doulas all say that having an experienced doula who knows her role is a positive situation for everyone involved. That said, there are a few grumblings from both sides. Doctors and nurses aren't happy when a doula oversteps her boundaries and advises her client on medical procedures or speaks on behalf of her client. Stories have also emerged of doulas persuading mothers to reject caesarean sections or epidurals when those procedures had become medically necessary. For their part, doulas have complained that nurses resent their presence and belittle their practices.

And parents such as the Smiths say hostility between their doula and hospital nurses heightened the already harrowing experience of childbirth. The Smiths' doula had prepared them for this, which is why they didn't tell the nurses who she was.

"We felt it would cause friction -- it's not a time when you want friction," says David Smith. "There were lots of moments where a nurse would come and check my wife's blood pressure or something like that, and the doula would say, 'Do you have to be so rough? That's hurting her. Can't you do something else?' And the nurse would say, 'I'm trying to be as gentle as I can, but I have a job to do.'

"I'd have to stop and talk to the doula after," David recalls, "and say, 'Is there a problem?' She said she had run into this sort of thing before, meaning if you told them you brought a birth helper, the nurses roll their eyes at you.

"But then I wasn't sure if it had as much to do with doulas or just this particular woman's personality." It appears it can be a bit of both.

Lisa Frances*, who is both a nurse and a doula, always warns her clients delivering in hospitals that doulas occasionally receive a less than warm welcome. "I just say that for whatever reason, they [doctors/nurses] aren't as accepting of doulas, they have their own views. I say you might have the nicest nurse in the world who is so accepting of doulas, but then you might get the nurses who aren't. And I always try to talk to the husband and say, 'It's up to you to stand up to them because some nurses try to control them.' Two summers ago, at a Toronto hospital this nurse was just completely rude to me. I went to heat up a rice pack [heat pad] for my client and she grabbed it away from me and went to heat it up, but when she brought it back it was still cold. She was against anything we were trying to do to help the client. She said, 'That could burn her.'

"One of the reasons I sometimes leave a birth with a bad feeling, even though the baby has been born and everyone is happy, is I don't like that tension. I'm an independent woman who is educated and I don't like to be treated like that by any nurse. As a doula you give yourself emotionally and physically, and you do it because you love to do it."

But Heather Ellis, a nurse who has worked in labour and delivery at Mount Sinai Hospital in Toronto for 24 years, says in her experience, doulas have worked out wellmore often than not.

"Listen, we are busy," she explained. "Mount Sinai is a high-risk unit, too. It's wonderful to think there is going to be one nurse dedicated for 12 hours to one patient, but sometimes it doesn't happen that way. If there is someone there to rub their back, support them and encourage them, it takes a huge load off us. Just as long as lines don't get crossed."

Crossing that line from emotional support person to medical advisor is the biggest complaint from doctors and nurses about doulas.

Dr. Jodi Shapiro, an obstetrician/ gynecologist at Mount Sinai, agrees there are doulas who are very good in their role, but she knows of others who overstep their position. "Some of the doulas feel strongly they have to be advocates for the patients. We are advocates for the patients. We obviously want what's in the best interest of the patients and I think it should be very clear a doula's only role is to support the patient and not make any medical decisions and not to provide any medical information," she says. "I do remember after delivering one patient who had a doula in the room, the doula asking me if she could give the patient some sort of herbal medication. There is no role for that in a hospital. If you want to have your baby at home, that's fine, but in a hospital we have a formulary of medications we prescribe and the doula shouldn't be prescribing any medications."

The doula's role as a strong proponent of natural childbirth is often the primary source of tension with the medical profession. Prior to the due date, doulas meet with expectant parents to discuss, among other things, their birth plan. And because the people who hire doulas are generally after non-medicated labours, these plans often include firm orders not to let them give in to an epidural or C-section.

"And we love birth plans, but sometimes you have to deviate from them," says Sheena Mavis, birthing program coordinator at B.C. Women's Hospital and Health Centre in Vancouver. "So there might be a conflict between what [they wanted] and what is necessary when they are actually at the hospital. With one woman, I read through the birth plan and she did not want an epidural. We did all the things you do in labour, such as showering, walking, ambulating, rubbing their backs -- and we have birthing balls they can sit on and bounce up and down -- to support her in not having an epidural. But she got to the point where she needed more pain management, so an epidural was suggested.

"The doula felt we could continue without one," Mavis recalls. "I've always left it totally up to the client and what they wanted, and this woman wanted an epidural, but the doula was feeling very ... well, it had been discussed prior to labour that her job was to support the woman not to have an epidural, so there was a lot of discussion. Eventually, she did have one." Mavis concedes that a doula is often put in this difficult position, as a client will say, 'Please, no matter what, support me inmy decision to not have an epidural,' and then she changes her mind."

The Smiths also eventually opted for an epidural after many long hours of labour, and their doula was fine with it. "But they put an enormous about of pressure on you to have a natural childbirth," explains David. "They tell you it's your choice if you want intervention but if you do intervene, certain things will happen to you. It's almost scare tactics, like if you have an epidural, you'll have problems breast-feeding."

Frances says any doula who persuades her client to not have an epidural or C section when they want one or when it is medically necessary is not a good doula. She says a competent and experienced doula will say, " 'Let's get as far as we can [before taking the meds].'

"You should be somewhere in the middle, but some people are so extreme," she says. "I know doulas like that, and there are clients who want a doula like that. But you can't push your client. She might have laboured for a long time and want the drugs, and you have to be there for them. But it's very frustrating for a doula these days because of the high rate of Caesareans and because [the nurses] are quick not to be supportive and to not try other things such as squatting. I had a client who didn't want a Caesarean and she had been pushing for a few hours, and they were telling her 'Caesarean, Caesarean,' and finally I said to them, 'Can she squat?' These beds at Mount Sinai and other hospitals were made to put a squatting bar in, but you say that and they don't even know where the squatting bar is. At this particular birth they did find it and we got her to squat, which opens up your whole pelvic area and she was able to birth her baby. Afterwards she couldn't understand why these people were telling her she couldn't."

Jacquie Munro, who has been working as a doula for 19 years in Vancouver, once spoke to a doctor standing outside of a delivery room who was in tears. "She said, 'Do you know the doula who is in there?' I said, 'No sorry, I don't.' And she said, 'Well you have to go in there because she just asked if I was old enough to have a medical degree and said her client was not going to agree to a Caesarean, but the baby is doing so poorly, we have no other option.' I said, 'I can't go in, but you go in there and ask the woman what she really wants.' "

Both doulas and doctors agree that no expectant mother with a doula should become uninvolved and let the doula speak for her. Munro says she gets very uncomfortable when a doctor or nurse has presented a situation to the patient and the woman then turns to her and says, "Jacquie, what would you do?"

Ellis is also frustrated when mothers appear apathetic in their own care. "A lot of times the doula will try and speak for the patient and the patient is kind of passive in the whole thing, which is not what we want," she explains. "We had a patient the other night who had problems in the past with sexual abuse and when the nurse was getting her history, the doula said to the nurse, 'We'll talk about it later.' And the nurse said to the patient, 'I have lots of time. We can sit here and talk about it no w,' and eventually the patient told her why she was worried." Ellis says the nurse stepped out to the hallway with the doula and asked her not to answer for the patient.

"Most are great," she says, "but maybe they've questioned something in their doula-like way -- you know, granola-ish, where they will say, 'Well, why don't we let Mary think about this for awhile.' And

I'm thinking, 'Oh sure, absolutely, no one is rushing anybody here,' but it's not me and it's not the doula who is having the pain, it's the patient. Sometimes the feeling you get is that you are the enemy. And if the doula is there, it's just not the same bonding process."

A misconception that appears to accompany the popularization of doulas is that a mother can't have a natural birth without one. "But what we want is for people to realize labour and delivery- room nurses are highly trained also in natural childbirth, and so even if someone doesn't have a doula, they can certainly have a natural delivery," says Ellis.

Similarly, a good doula is not opposed to the benefits of modern medicine. And when the Smiths had their second child they put in a call to their doula. "And we told her we didn't want to go through that [pain] again, and at the first point that Jen felt she didn't want to deal with it, we were going to go for an epidural," recalls David Smith. "And she was totally cool with it."

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