The Doula Magic: Lowering Cesarean Rates
By Jessica English, CD/BDT(DONA), LCCE, FACCE (Originally published March 2017)
Introduction: Doulas Reduce Cesareans
Whether I’m talking with parents, training nurses and doctors to support physiologic birth, or advocating for insurance coverage for doulas, I often mention the impact doulas have on lowering cesarean rates. It’s a hot topic right now, as national attention has turned to reducing the current U.S. cesarean rate of 32.2 percent (Centers for Disease Control). Other countries have set their sights on similar reduction measures, as cesarean rates reach as high as 51.8% in Egypt and 55.6% in Brazil (Betrán et al. 2016), for example.
Depending on the study or review, doulas have been shown to reduce cesareans by anywhere from 28 percent (Hodnett et al., 2012) to 56 percent (Kozhimannil et al., 2016) for full-term births. When I share that information, people are usually impressed but also often look at me curiously and ask, “Why is that?” It’s a great question. In her blog post “The Evidence on Doulas,” Rebecca Dekker of EvidenceBasedBirth.com offers a great conceptual model for why continuous labor support improves outcomes. Aside from that model, I haven’t seen many explorations of exactly why doula support turns out to be so helpful. Let’s explore the doula magic and how it helps to reduce the risk of a cesarean birth.
Choosing a Birth Place and Provider
In a New York Times article last year, “Reducing Unnecessary C-Sections”, Tina Rosenberg offered this quiz:
What’s likely to be the biggest influence on whether you will have a C-section?
Your personal wishes.
Your choice of hospital
Your baby’s weight.
Your baby’s heart rate in labour
The progress of your labour
According to research, the answer is B — your choice of a hospital. Other studies also show that choosing a birth center (Stapleton et al, 2013) or a home birth (Cheyney et al, 2014) reduces a woman’s risk of cesarean. Your personal provider’s cesarean rate also impacts whether or not you will have a cesarean birth.
So what does choosing a birth place or provider have to do with doulas? As part of our role prenatally, doulas help clients think through their choice of a provider and birth place. We ask about their relationship with their provider with questions like, “How is it going at your office visits?” or “How did it feel for you when your provider said that?” If clients tell us that they want to avoid a cesarean, a doula can suggest that they ask about their provider’s cesarean rate and if they’re having a hospital birth, the rate at that hospital. If there are concerns, doulas encourage our clients to explore their options and we support them if they decide to make a change. For clients who are motivated to avoid a cesarean birth, we can also share the research that shows that the provider and birth place a person chooses can make a difference.
Now that’s not to say that the doula tries to influence a client’s choice of providers. Guided by DONA International’s Standards of Practice and Code of Ethics for birth doulas, we respect a family’s right to make their own decisions about the best place to have their baby. The doula shouldn’t express an opinion, but we can definitely support families as they think through the decision on where to give birth and who will support them—decisions we know impact cesarean rates.