The Birth Doula-Helping to Ensure Breastfeeding Success in the Hospital

Joining a family for the birth experience is both a great honor and a great responsibility.  Doulas enter the most amazing place as they simultaneously witness and support in a miracle.  It is sometimes difficult to focus on the tasks and not get caught up in being merely a spectator in the blooming of a birth, but the focus comes with the realization that the goal is to support the family. A doula plays a crucial part in how the birth will be remembered and how breastfeeding will be initiated.  

Birth and breastfeeding are as closely related as a key to a lock.  Often, moms are discouraged by difficulty in breastfeeding which is often brought on by birth practices or protocols during the immediate postpartum period.  Many routine procedures jeopardize breastfeeding success. Having an understanding of how medications effect a baby can be a huge advantage to assessing the breastfeeding relationship.  Doulas need to keep a mental note of medications being administered and the type of birth a mom experiences in order to provide the best postpartum breastfeeding education and support.  A skilled doula can avoid long-term problems by anticipating possible consequences and formulating immediate solutions to common problems.

A doula can also be proactive by assisting in formulating the Birth Plan.  This is an excellent time for the birth assistant to explain all the procedures and the pros and cons of each intervention.  Once a mother's wishes have been spelled out, the doula is able to advocate for the family throughout the birth day. 

The keys to supporting a mom in the hospital begin before her first contraction.  Statistics show that most families reach their infant feeding decision prenatally.  It is important to offer education during prenatal visits with clients.  These scheduled visits are great opportunities to discuss what the client knows about breastfeeding.  One open-ended question I often begin with is, “What have you heard about breastfeeding?”  This question will often reveal fears, concerns, misconceptions and the mother's confidence level. 

Once the desire to breastfeed has been established, the doula’s role has a new facet.  The mom will rely on the doula to support her in this momentous decision. Breastfeeding is a brief event (in comparison to the entire life of an individual), that has life-long effects.  The research and resources about formula risk is abundant and breastmilk will insure protection from many childhood and adult health conditions.  I take breastfeeding support as seriously as all aspects of my work, and commit to helping a mom reach her breastfeeding goals—whatever they may be.

Observation is the first key to breastfeeding success.  Observations can even be made prenatally.  Statistically, obese, diabetic, and older moms (over 40) may have delayed Lactogenesis II (onset of copious milk supply).  Additionally, clients who birth cesarean may not experience fullness in the breasts until day four.  Being armed with this information is a huge advantage to the mom who is convinced she “has no milk” based on breast fullness postpartum.  Moms need to be reminded that the infant had a direct line to the all-you-can-eat buffet while in utero and does not enter the world starving. 

A doula’s immediate postpartum role is to encourage skin-to-skin and protect the “quiet hour” for bonding.  Doulas may encourage the mom to slightly recline, place Baby between the breasts (somewhat vertically) and assist as the baby scoots down to self-latch.  Doulas and hospital staff may offer additional assistance to the medicated mother if necessary. Most babies when placed skin-to-skin will initiate breastfeeding within the first two hours postpartum.  I encourage a "babymoon" much like a honeymoon where the family commits time and attention to love, learn and hold the new baby.

Medication taken during labor can also affect the breastfeeding outcome.  Natural pain management is the least likely to result in breastfeeding issues.  If medication is necessary, generally, the epidural is more desirable than anesthesia for c-section births.  The epidural allows for earlier contact with mom and longer nursing sessions.  The infant born via cesarean will often be sleepy and lethargic, especially if anesthetics were administered for a prolonged period.  Doulas can help with positioning, supporting the baby at breast, and helping to arouse the sleepy baby.

The baby who was exposed to narcotics during birth may be agitated and restless.  These medications are often administered with a promise to “take the edge off” during labor. Sometimes medical staff try to minimize the effects of labor medications, but it is important to understand that all medications can affect breastfeeding. Fortunately, with the support of a well-prepared doula, the transition from belly to breast can be smooth and natural. 

It's Time to Make "Doula" a Household Name

What is a doula?  

How many times has a doula been asked that question? It is a profession rarely highlighted in career choices and fewer people understand the role of a doula than that of a dog walker.  The services that a doula performs are fundamental to birth, yet even Micorsoft places a red, squiggly line under the word, expressing ignorance of the vocation.  

I was confronted with naiveté of society recently while attending an adult baseball game.  The pitcher threw a fastball to the batter who hit a line drive straight back to him.  The pitcher neither ducked nor got his glove up in time--taking the ball directly above his brow.  He went back, meeting the mound with all his weight.  There were gasps from the stands and players began to swarm around the injured pitcher.  Within seconds, as the huddled group decided how to respond, a voice projected towards all the on-lookers, and someone yelled, "Get Christy Jo, she works in a hospital!"  If it wasn't such a somber time, I would have burst out laughing.  I was sitting next to a friend who was a RN, yet they call for the Lactation Consultant/Doula?  What diagnosis did they expect?  The only response I could have offered (in my field of expertise) is, "Put some breast milk on it!"  Of course I can joke about it now since the player was transported to the hospital, had a few tests performed, observed for a few hours, and then discharged.  As I recount this story, I validate the need for education on the work and scope of a doula. What is a doula?

I could offer the text book definition: 

doula [ˈduːlə]
n

(Medicine/Gynaecology & Obstetrics) a woman who is trained to provide support to women and their families during pregnancy, childbirth, and the period of time following the birth
[from Greek doule female slave]

But that would only perpetuate the anemic understanding of the term.  A doula's skills and services are as varied as the women who perform them. To describe a doula as merely a labor assistant is equivalent to describing a sculpture, painter, metal smith and musician as an "artist." Does that tern explain or adaquately portray the gifts and talents of Picasso, Rembrandt, Degas or Michelangelo--absolutely not.  The general term is an insult to the master of the clay, dictator of the canvass and matriarch of the Renaissance.  An artist is so much more than the word suggests, yet, I suppose it is a starting point.

What Are a Doula's Qualifications?

There are some general attributes that can be given to most doulas.  Doulas receive specific education in the perinatal field.  Training can come in the form of mentor-ships or formal education.  Many doulas have completed a certification program that holds them accountable to the certifying agency.  In order to complete certification, students must complete numerous steps--all which enhance the skills and knowledge of the doula.  Certification may involve taking a specific training course, completing reading assignments, fulfilling observational tasks, attending coalition/support groups, role playing. accomplishing research projects and passing an exam.  Certified doulas are also required to re-certify for maintenance of the title.  

Doulas Should be Hired Early in the Prenatal Period

Doulas realize the importance of establishing a relationship with clients prior to attending their birth.  This is as very vulnerable time for a woman, and trust is of the most importance.  It is crucial to learn the family’s history, mom's preferences and develop a comfortable friendship.  Doulas often offer prenatal classes to their clients as part of the doula service.  Once a client explains her ideal birth, the doula can begin working towards that goal during the prenatal meetings.  Doulas may teach clients birthing and laboring positions or relaxing techniques that can be practiced between meetings. A well-prepared client is empowered and confident as the "birth day" approaches. The more comfortable the clients are with the doula, the more at ease they will be at the birth. The prenatal investment is paramount to a tranquil birth.

"My advice to every dad, 'Get yourself a doula'!" Johnathan F.

Doulas take the role of servant to heart, offering emotional and physical support throughout labor.  They are a valuable part of the team in a home birth, birth center birth or hospital birth. Whether a mom chooses a natural or medicated birth, a doula is equipped with information to support the family.  Even in the case of a planned or emergency C-section, a trained professional at a mom's side provides a calming effect for everyone present. 

Doulas often advocate for the family and remind the laboring mom or couple of their predetermined birth choices.  They guard the birth from distractions and intrusions.  Doulas anticipate the needs of the birth coaches and laboring mother--offering ice, wiping a brow, massaging feet and securing additional blankets--but most importantly, a doula is present.

In a hospital setting, nurses are required to complete so many routine tasks, that they are denied the luxury of lingering at the laboring mother's side; in contrast, the labor doula offers the security and comfort of continuous companionship. So often questions arise when the medical staff are not in the room.  A doula can help to answer questions and offer confirmation that birth is proceeding as expected.  A doula not only interprets the birth for those present, but also anticipates the most likely imminent events. I have had fathers watch in amazement as their soul mates go through a transformation that they could have never imagined; and with a few encouraging and assuring words, they can return to a state of awe rather than one of panic and disbelief.  

Partners frequently grasp for ways to offer support and comfort to their soul mates.  A doula helps to guide the process.  The doula also offers a second pair of hands for relaxation and massage as well as relief for a partner that may need a few moments to refocus.  Sometimes couples are more comfortable with the doula taking on a larger role in the production.  I have been at births where I have been asked to perform a monologue only calling in extras during specific scenes.  The couples had a well-thought out plan that involved the doula coaching and comforting Mom, providing direction and soothing measures.  Dad was free to record the event, contact relatives and whisper in his wife's ear.  A doula is a servant, performing any task that makes the birth more comfortable, enjoyable and memorable for her clients. 

There is no right or wrong way for the doula to assist, as long as she is working within her scope.  Doulas understand that the birth and the decisions are at the discretion of their clients, they just serve to make the transition form womanhood to motherhood as smooth and enjoyable as possible.   

Does a Doula Make a Difference?

Studies have shown that the use of

a Doula during labor and delivery can have

the following beneficial effects:

  50% reduction in the cesarean rate

  25% shorter labor

  60% reduction in epidural requests

  40% reduction in pitocin use

  30% reduction in analgesia use

  40% reduction in forceps delivery

  Improved breastfeeding

  Satisfaction with birth experience

  Decreased postpartum depression

*Adapted from Mothering the Mother--

How a Doula Can Help You Have a Shorter, Easier and Healthier Birth by M.H. Klaus, J.H. Kennell, and P.H. Klaus; Addison-Wesley Publishing Co., New York (1993).

Let a Doula Be Your Epidural

There are far more benefits to having a doula at a birth than there are to having an epidural--yet only one of these are talked about at hospitals, in moms groups or in the main stream media.  That needs to change! Let's remind moms that they don't need to--nor should they--enter this time alone or unprepared.  Moms can take birth back, and doulas can help.

Author's Note: I have been in the perinatal field for over a dozen years.  Originally, I entered the field as a Lactation Consultant.  Many of my breastfeeding clients had issues that originated in the hospital. I quickly realized I wanted to spend a more time in the area of prevention to avoid the numerous  postpartum visits where I spent days, sometime even weeks fixing what could have been avoided in the first place. 

More information about Christy Jo's Doula Services or Doula Connect (a service that matches clients with doulas) can be found on her website 

Breastfeeding Moms Have a Target on Their Breasts

The national increase in breastfeeding rates has caused the formula companies to stand up and take notice.  What is great news for moms, babies and society could prove disastrous for formula companies and their stock holders--unless they can grab part of the growing market.  

Formula companies, like most thriving companies, strive to make a profit and constantly plot how to increase their earning. Some companies do this in conscionable ways while others are not so scrupulous--allowing visions of profit to cloud their judgement, they tend to concentrate on profit regardless of quality or health implications. Any assumption that these companies have the best interest of baby in mind is ludicrous. They continue to use the cheapest ingredients (corn syrup, vegetable oil, sucrose, etc) to allow for greater income--the bottom line, their loyalty is to their stock holders and wallets, which leads to many of their marketing strategies. 

The earlier a company can obtain a loyal customer the better.  Many ads and products vie for the prenatal shopper. Brand loyalty can begin with a selection of prenatal vitamins or supplements.  Many pregnant women are succumbing to the offers of registering for baby formula for baby showers and collecting coupons before they even deliver a baby.    

Formula companies previously used more passive marketing techniques such as offering free feeding advice on warm lines, suggesting formula for moms on the go, or offering quality gifts to new moms; but the days of subtleties are over.  The breastfeeding market has become too large to ignore, so "if you can't beat them, market to them." 

Formula advertisers are the kings of spin.  Moms have switched to formula after the huge marketing campaign announcing that breastfed babies need a Vitamin D supplement since breast milk does not contain the sunshine vitamin.  Of course, none of the ads reveal that breast milk was not meant to contain Vitamin D, which ideally comes from the sun. Since formula contains it, mothers began to question whether or not their milk was complete--the marketing strategy paid off, consumers were either purchasing formula containing Vitamin D or the Vitamin D supplements (manufactures by Enfamil) that state clearly on the box, "Essential for all Breastfed Infants." Of course the box top boasts, the "brand recommended by Pediatricians."

Perhaps the most disturbing trend in formula marketing occurred this month with the release of a new product directly targeting and undermining breastfeeding moms.  The May 11, 2013, release of a Similac for Supplementation confirms the company is desperately trying to increase its customer base.  This blatant attempt to sabotage the breastfeeding relationship is outrageous.  This new product states, "for breastfeeding moms who choose to introduce formula" compared to the other formulas which are only for "formula moms who choose to introduce formula?" This is a pathetic bid for the breastfeeding audience.  Unfortunately, it could just work, especially since this message is being perpetuated by a new study released two days later in Pediatrics.  The article's release date (occurring the same week this formula hit the shelves) is highly suspect.  It may seem like a conspiracy theory, but as well-equipped as the strategists are, the timing is not a coincidence and neither is the correlation between Abbott and the co-author of the study, who was previously employed by the maker of Similac.

The timing could not have been better orchestrated. It would be interesting to see if an advertisement for Similac ran in some of the major papers who posted the flawed supplementation study.

Formula companies seem to have an uncanny way of acquiring prestigious spokespeople for free. First, the doctors in the hospitals, now researchers for Pediatrics. No wonder the companies boast billions in profit annually, they have inside help.

The flawed, and poorly-constructed study published by Pediatrics sent the media on a sharing frenzy. The article made its way into nearly every large newspaper with headlines proclaiming that formula helps to breastfeed (an oxymoron exemplified).  Similac, Enfamil, and other artificial human milk companies could not have been handed a better gift. Few editors critiqued or even read the study prior to plastering the headlines across front pages.  The study, released online May 13, 2013, and published in Pediatrics, consisted of forty subjects-- an anemic sample size. The conclusion, after confirming that  15 of 19 mothers were still breastfeeding at 3 months, compared to 8 of 19 in the control group--a difference of 7 babies--was that babies given formula continue to breastfeed at higher rates. Not only was the study not supported by a clear hypothesis, the subjects were not homogeneous.

The clear conflict of interest was also document by a disclosure statement by the co-author, who "served as a paid consultant for Abbot Nutrition, Mead-Johnson, Nestle SA and Pifzer Consumer Products." Obviously, he must have a bias towards the necessity of formula to serve as a consultant for these companies. In fact, a more responsible study could have centered around supplementation with donor milk, if marketing formula was not one of the goals of this study. Pediatrics and its peer review council will surely continue to come under fire for publishing such an insult to true research. They acted in an irresponsible and unethical manner by endorsing this premature study. Although much of the damage has irreversibly been done, there are several rebuttals and informative articles being shared that are well thought out and deserve recognition   It is unfortunate indeed that newspaper editors will not be publishing any of them.  Dr. Alison Stuebe a member of Breasfeeding Medicine provides a response to the published study. Dr. Jack Newman added valuable insight to the study by posting his own commentary. 

As a service to breastfeeding mothers, and a way to expose the flawed research Birthing, Bonding and Breastfeeding conducted a survey asking mothers to respond if they were able to exclusively breastfed without formula supplementation. Within 24 hours over 340 moms confirmed their breastfeeding relationship was protected by choosing not to supplement.  Maybe from this result we could conclude that 99% women who use Facebook exclusively breastfeed. As ridiculous as this statistic is, it shows the parallel to how numbers can be manipulated and the erroneous conclusions which were drawn from the Pediatrics study.

Formula companies are missing out on a large portion of the infant-feeding market. Breastfeeding moms stay vigilant.  If you desire to breastfeed exclusively, the evidence is overwhelming in support of avoiding supplementation.  Babies are born to breastfeed and the protecting the relationship by keeping Mom and Baby together is the best practice for success.  Women who need additional support or medical advice should consult with their breastfeeding-friendly physician, Lactation Consultant and Peer Support Groups.

Editor's Note: I hope we can promote the message that moms do indeed have the milk they need when their babies are born. Products and flawed studies continue to undermine instinct and nature. We need to dispose of the idea that milk will "come in" or that mother's around day 3...engorgement does not have to happen, and if any more milk were available on day one, theoretically the baby could overfeed since all he wants to do is suck! We don't need to "wait" for anything. Just keep the dyad together and all the "issues" can resolve themselves.