Making Mothers Count in Medicine: Valuing the Work of Doulas in Perinatal Care
When our medical system comes up against the limits of our measurements, whatever is hard to compress into data is neglected. The exclusion of doulas from what counts as care is a particularly egregious example.
Photo by David Veksler on Unsplash
by Leah Libresco Sargeant
To talk to a doctor, you have to be a translator. A patient has to make his or her experience accessible to the doctor, but the resulting translation can be clumsy. Think of those pain scales, with the laminated little faces, shading gradually from serenity to sorrow to screams. The doctor needs some kind of standard in order to apply diagnoses and to conglomerate individual patients into statistics. But the gap between the patient’s experience and how it’s measured is often, itself, painful.
When our medical system comes up against the limits of our measurements, whatever is hard to compress into data is neglected. The exclusion of doulas from what counts as care is a particularly egregious example. Doulas are trained helpers who stay with a laboring mother throughout a birth. They aren’t medical professionals, can’t dispense drugs, and don’t direct the work of doctors or nurses. If a mother wants the help of a doula, she has to pay for it herself—insurance doesn’t cover this kind of care.
“Doulas help to bridge the gap between patient and provider—a gap that exists for more than just laboring mothers. Recognizing the worth of doulas’ work should spur us to ask where else patients are missing out on care that is undervalued because it isn’t easily quantified, or because it is too tender, slow, and personalized to look like what we expect of medicine. ”
But if you got the effects of a doula’s care from a pill or an IV infusion, instead of a person, it would be covered with no copay. The Affordable Care Act expanded coverage for preventive services, including prenatal care, so that patients could help head off serious problems without being dissuaded by the price. Preventive services pay for themselves—the small cost of screening or support makes it much less likely that women and their babies will face greater danger and higher costs later.
In a study in Birth, researchers found that doulas met this standard. When mothers on Medicaid received prenatal care from a doula, they were less likely to deliver their children before 37 weeks or by C -section. Avoiding these complications meant that the government paid less for the mothers’ and babies’ care—so much less that the researchers argued that Medicaid would save money by paying doulas and expanding access to their services. (The study was not randomized—it compared mothers in a special program to a much larger sample of mothers on Medicaid).
If a doula isn’t practicing medicine, as conventionally understood, how does she have such a large effect on the outcomes for mothers and babies? What a doula has to offer is presence. A doula is present continuously throughout birth, focused on being available to the mother, while nurses and doctors juggle a caseload of several patients.
Stitching together studies conducted in 1997 and 2001, Karla Papagni and Ellen Buckner argued in the Journal of Perinatal Education that there is a sizable gap between mothers’ expectations of support from nurses during labor and the help they actually receive. Mothers who were delivering their first child expected a nurse to spend about half her time “offering physical comfort, emotional support, information, and advocacy.” In practice, researchers observing conventual nursing found that nurses “spent only 6–10 percent of their time engaged in labor support activities.”
Nurses might like to spend more time with patients, but hospitals, focused on the bottom line, lay heavy burdens on their staff. When they choose to measure the effects of short staffing, the feelings of both mothers and nurses may not even be asked about, or may be compressed into a simplistic scale like those 1–10 pain ratings.
A busy nurse offers limited kinds of support, likely sticking to medical interventions, while a doula may offer a broader range of help. When a mother’s labor is progressing slowly, a nurse might adjust a medication like Pitocin, intended to increase the strength of contractions. A nurse may be less likely to suggest a laboring mother get up and walk around, which might have a similar effect with no need for an IV. A doula can walk the halls with a mother and support her weight during contractions while the nurse has to run to the next room, summoned by beeping machines.
Even when nurses offer the same support or advice that a doula would, their presence may be more emotionally complicated for the mother. To an extent, when a nurse is present in conventional care, it means something is going wrong or that the mother is being actively monitored. The nurse’s visits, whether to adjust monitors, perform a cervical check, or administer medication, are often uncomfortable and an interruption of the mother’s work. A doula, able to focus solely on support, doesn’t have to switch back and forth from calming touch to intrusive touch.
The medical system can be so painful to navigate that simply having a kind person present as a buffer and a support can help patients, even when that volunteer has no special qualifications. One randomized study of 149 women paired laboring mothers in the treatment group with untrained volunteers, rather than doulas specifically. The volunteers focused on providing “comfort, reassurance and praise.” The mothers paired with volunteers needed less pain medicine, experienced less anxiety, and were more likely to say after birth that they’d coped well with labor.
The study of volunteers is threatening to the professionalized birth system. It’s one thing for doulas to have a positive effect—they may not go to medical school, but they do have training and certifications. If a friendly volunteer can meaningfully improve medical outcomes and reduce the need for analgesics, then there’s a real gap in what the experts do.
The volunteers were less helpful than doulas—they didn’t make a significant difference to outcomes like C-section rates and they didn’t save the hospital or the patient money. But when we view women’s experiences primarily through their hospital bills, we neglect their experience and their dignity as human beings.
Pain drugs are covered (at least in part) by insurance because they “count” as medicine. The birthing assistant who puts a woman at ease and makes her less likely to request the drugs doesn’t count in the same way. Both treatments make the numbers on the pain cards go down, but we don’t think kindness counts as real medicine—it isn’t professional. The volunteers are improving outcomes that hospitals rarely track—there’s no emotional Apgar score given to the mother after birth.
I’d like to see doulas incorporated into best practices for births. I hope to see them covered as preventive care, without any cost to the mothers. I hope they will be recruited and well paid to work with low-income mothers, who are at the most risk and least listened to when they enter a hospital.
I hope most of all that valuing the work of doulas means expanding what we think of as medical care. There is a case to be made for doulas even under our professionalized, cost-focused, patient-neglecting paradigm. But if we include them without recognizing their full value, we’ll miss the chance to be attentive to other gaps in the care patients receive.
Mothers and children require ongoing support, long after the family has headed home from the hospital. Once the time of greatest medical risk has passed, our individualistic culture can leave parents, especially mothers, feeling isolated. A culture of solidarity can soften the strain. Parents need the support of meal trains, babysitting, and just conversation with someone big enough to talk. The medical safety net focuses only on the most dangerous problems—baby’s weight gain, mother’s depression, hazards in the house. Care requires much more.
Doulas help to bridge the gap between patient and provider—a gap that exists for more than just laboring mothers. Recognizing the worth of doulas’ work should spur us to ask where else patients are missing out on care that is undervalued because it isn’t easily quantified, or because it is too tender, slow, and personalized to look like what we expect of medicine.
Patients are not collections of lab test results, symptoms, and pain scores. Only by putting their dignity at the heart of their care can our medical system be truly holistic.
Leah Libresco Sargeant is the author of two books, Arriving at Amen and Building the Benedict Option. She runs "Other Feminisms" a Substack community focused on interdependence, not autonomy.