Historically, women have been attended and supported by other women during labour. Yet in many places throughout the world, including Hong Kong - and because more women give birth in hospital than at home - continuous support during labour has become the exception rather than routine. Experts say this may contribute to the dehumanisation of women's birth experiences.
In a systematic review published in the Cochrane Library last year, a research team from the University of Toronto's faculty of nursing analysed data from 21 trials from 15 countries involving more than 15,000 women in a wide range of settings and circumstances to assess the effects of continuous, one-to-one intrapartum support, compared with the usual care.
The researchers found that the best person to provide support is one 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. Enter the doula.
Recently relocated expatriates Tiffany King, 35, and Lauren Ullman, 31, hired doulas - 'women who serve' in ancient Greek - for their first babies. They were both hoping for natural births and wanted to create the necessary support by having a birth companion present.
King suffered from high blood pressure and was induced at 381/2 weeks; she had to undergo an emergency Caesarean section to prevent her baby from going into distress. 'Even though I had a Caesarean section, I was still able to labour naturally 90 per cent of the time. Because of my doula's coaching, I was able to get through the pain; it was totally worth it in the end,' she says.
Ullman, who was 21/2 weeks overdue, went into labour the day before she was to get induced and delivered a 4.2kg baby without drugs or stitches. 'My doula's massage during labour, suggestions on birthing positions and reflexology points and support for my husband were invaluable,' she says.
Doulas in Hong Kong are a relatively new phenomenon. There are about 10 doulas mostly serving the expat and Western-educated Chinese population. But doulas have been present across history and cultures as experienced mothers assisting new ones.
These days, a doula is a birth companion who provides emotional and physical support and advice to the mother. Most of the doulas in this city, such as Eugenie Vallot-Perraud, a doula who moved to Hong Kong from Paris in 2009, also provide prenatal care and post-natal support. Each often works with a backup doula to ensure either she or the backup is present during the birth, and will often be on call from two weeks before the due date.
A birth doula supports the expectant mother before, during and after birth, while a postpartum doula supports the mother after. In contrast, midwives can undertake medical procedures such as checking dilation and the baby's heart rate.
'We help the mother achieve the birth she wants,' says Kathy Kitzis, a Hong Kong-based doula and massage therapist.
Doulas are most common in countries where there has been a trend towards the medicalisation of childbirth, such as the US, says Hulda Thorey, midwife and director of Annerley, the maternity and early childhood group. 'We are bound to have more doulas in Hong Kong as time passes.'
'First-time expectant parents and expatriates who are new to Hong Kong and have no family and friends nearby will find a doula helpful and supportive,' says Dr Patrick Chan, a specialist in obstetrics and gynaecology. He says expectant parents should consult their doctor and hospital to ensure a mutual understanding is reached, and that the hospital has no restrictions on doula care.
'It's important for the doctor, patient, midwife and doula to work as a team to optimise a good birthing experience, but also have an understanding that ultimately the safety of the fetus and mother takes priority. It's important to support the mother during the natural birthing process - and in case the process deviates from expectation and intervention is required.'
Lizzie Purnell-Webb, a Hong Kong-based doula with a nursing background, says past birth experiences that have gone poorly are another reason couples tend to seek doula support. Doulas also give great support for dads. 'It may be difficult to see the one you love in pain,' says Purnell-Webb. 'The doula is there to provide advice and suggestions to the couple during the birth planning process.'
In the University of Toronto study, the continuous support was provided either by hospital staff, such as nurses or midwives; women who were not hospital employees and had no personal relationship with the labouring woman, such as doulas or women who were provided with a modest amount of guidance; or by companions of the woman's choice, such as her husband, partner, mother or a friend.
The researchers found that women who received continuous labour support were more likely to give birth 'spontaneously', without Caesarean, vacuum or forceps. In addition, those women were less likely to use pain medication, were more likely to be satisfied, and had slightly shorter labour. Their babies were less likely to have low five-minute Apgar Scores, a measure of a newborn's health. No adverse effects were identified.
A 1997 paper by the World Health Organisation's Technical Working Group published in the journal Birth explains that doula support may include praise, reassurance, measures to improve the comfort of the mother, physical contact such as rubbing the mother's back and holding her hands, explanation of what is going on during labour and delivery, and a constant friendly presence.
These are tasks that could be fulfilled by a nurse or midwife, but they are often preoccupied with medical procedures. Given the short supply of hospital resources for delivering births, the doula could provide this continuous support, especially in a hospital setting where you do not know who is going to be on duty.
To select a doula, prospective parents can interview candidates to find one with a background, experience and personality that they feel most comfortable with.
Price is also a consideration. A birth doula can cost about HK$15,000, whereas a labour doula, who stays up until the birth (in the public hospital system only one companion is allowed to attend) costs HK$10,000.
This is three times higher than the cost of hiring an experienced doula in the United States, says King. In effect, the cost of having a doula is similar to that of an epidural and the services of the anaesthetist in a private hospital.
Doula fees are commonly not covered by medical insurance companies.
Apart from cost, the drawback of having a doula is that eagerness to ensure a natural birth can lead to them overstepping the line in the delivery room, where they may not appreciate the medical realities.
Since doulas are unregulated in Hong Kong, experience and training may also vary from one doula to another.
But both King and Ullman felt that their doulas were respectful, and say they would hire them again. Chan adds: 'So far I have had very positive experiences when a doula is involved in a patient care.'
The number of birth companions operating in Hong Kong at present
www.annerley.com.hk;  Tel: 2983 1558
www.doulabirthstory.com;  Tel: 6496 4318
www.kathykitzis.com;  Tel: 6340 4687
www.amotherstouch.com.hk;  Tel: 9521 2347
firstname.lastname@example.org ; Tel: 6113 8491
In line with World Doula Week (22-28), there will be a free film screening of Doula! The Ultimate Birth Companion 2010, a 50-minute documentary featuring three births, tonight, 7-9pm, at Kathy Kitzis, Room 202, Ivy House, 18-20 Wyndham Street, Central
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