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April 2, 2001
Handmaidens for Hire
Doulas perform labor of love
By Meredith Wadman

illustration: Barbara Shone

As a first-time mom with a lot of education, I should have cruised through pregnancy. While studying medicine at Oxford, I had helped deliver a dozen babies and had watched midwives coach novice and veteran moms through several natural births. I had seen epidurals and forceps used, and I'd seen a fair number of cesarean sections performed as well. What's more, my father had been an obstetrician and my mother a nurse. I felt comfortable in a delivery room and knowledgeable about all of the procedures performed there.

My husband and I had committed to having a natural birth, and I was confident that my familiarity with the birth process would be enough to support me through the experience. As Tim and I prepared for the arrival of our first child, however, we realized that I would need more than just confidence to get through the birth successfully. Both our families lived thousands of miles away, and while the hospital nurses were certainly competent, they were also very busy. The bottom line was this: Only Tim would be there to offer the constant, unwavering support I would need in order to have the medication-free birth I hoped for.

Tim is not a "touchy-feely" guy. Nor is he a medical type. He'd just as soon leave anything related to blood, pain, or hospitals to doctors. He even contends that there's a lot to be said for the days when dads-to-be paced the waiting room. I imagined him sitting in a corner of the delivery room, or rubbing my back at the wrong place and time, or bolting for fresh air when things got gory. For both our sakes, I wanted someone with experience to help with the hand holding -- someone, I have to admit, who was more of a nurturing "wife" than a hesitant husband.

Finding a birth partner

Early in my pregnancy, I had seen an article in the New York Times praising a new yet ancient kind of birth assistant. Doulas (pronounced DOO-luhs, from the Greek word for "handmaiden") are women who are trained to offer physical and emotional support throughout labor. Unlike midwives, they don't read fetal monitors, perform internal exams, or deliver babies. Their aim is to coach and "buoy up" the laboring woman, using everything from verbal reassurance to massage.

According to medical literature, doulas have been remarkably successful. In randomized controlled trials of first-time moms, women with doulas were 51 percent less likely to have cesarean sections than those without. Their labors were as much as three hours shorter, and their epidural rates were one-seventh those of women who didn't have doulas. A doula's presence also markedly reduced the use of forceps and contraction-inducing drugs.

I didn't need any further persuasion. I gathered a list of local doulas from the Doulas of North America, the largest professional association of doulas (link below). I made some calls and gathered brochures. But then I procrastinated.

Mainly, I was hesitating about the $500 fee. (Doula rates in Washington, D.C., where we live, have since climbed to $600-$800.) Doulas generally charge a flat fee for services that include pre- and post-birth home visits and support throughout labor. Very few insurance plans cover their services. I was about to go on an unpaid maternity leave, so I was tempted to try to manage without one. But as the inevitable day grew nearer, my anxiety overcame my frugality. I finally set up an interview with the woman who sounded like the best fit for us.

Aimee La Buy Smith talked with us in our home for two hours one Saturday evening when I was 38 weeks pregnant. A petite, 34-year-old mother of two, she had left a career in labor and employment law to pursue her passion as a doula. "It really felt pretty much like a spiritual calling -- more a call to a vocation than to just another type of work," she explained to me later. Aimee accepted us as clients. She turned out to be the best investment we made in our baby's birth.

A friend indeed

Two days later, my doctor induced me, because of worries about the baby's growth. I braced for the worst. I had been warned that oxytocin (Pitocin), the drug given to prompt contractions, makes labor more difficult for many women. After taking oxytocin, my contractions came on abruptly and grew quickly in intensity and length. By the third hour, they were coming almost on top of each other, with double peaks on the machine readout.

Aimee, who was present throughout, was an angel of comfort. She massaged my lower back during contractions, using a technique called counterpressure that makes the pain more bearable. She wiped my forehead with a cool white washcloth. She held a glass of water repeatedly to my lips.

She also became a voice of confidence and sanity at the end of a very long tunnel. "Picture the uterus pulling up on that cervix, opening it for the baby's head," she said soothingly. "This is a big one; every bit of pain is opening that cervix. There. That's another contraction that you never have to have again."

"You're very brave," she said. "I'm so proud of you. Tim's so proud of you. You're over the peak on this one. You're coasting down the backside."

"Is Tim here?" I asked occasionally. Sometimes he was, and he would come over and lay a hand on my shoulder. Sometimes Aimee would say, "He's just stepped out for a few minutes." (Tim explained later that he had to have breaks, that watching me in so much pain was impossible otherwise.)

As I entered "transition," the late stage of labor just before pushing begins, I thought the pain would break me in half. I began asking for an epidural. "But you're doing so well," Aimee reassured me. "You can do this naturally, Meredith."

"How far do you think I am?" I asked pathetically. (At my internal exam four hours earlier, I had been 1 centimeter dilated.) Aimee refused to let me think in terms of centimeters.

When I began screaming with every contraction, Aimee screamed with me. After five hours of active labor, my doctor arrived and pronounced me 8 to 9 centimeters dilated. I felt relieved it would soon be over. Then he said, "I'll be back in a couple of hours," and my heart sank. Surely I couldn't endure this pain much longer.

Aimee didn't think I would have to. She immediately suggested that I get up and labor on the "throne" to get gravity working for me. With her support, I hobbled to the toilet. I had been there for ten minutes when I got the urge to push. "Don't push!" exclaimed a nurse who had come in to check on me. She hurried off, while Aimee stayed with me and eventually helped me back to the bed.

Soon after, the on-call doctor rushed into the room and set up his tray at the foot of the bed. His internal exam confirmed that I was fully dilated. Aimee began coaching me on how to push. Meanwhile, the nurses tried to locate my doctor. He got back four minutes before the baby's head appeared. I pushed several more times and Bobby emerged, wide-eyed and calm, a five-pound-fifteen-ouncer with terrific Apgar scores. Aimee helped me get him nursing. My reserved husband looked at his son and cried with joy.

Aimee retreated to a chair in the back of the room while we phoned our families. I'm not even sure when she left, she was so unobtrusive.

"Aimee was a godsend," I wrote in my journal the next day. "Her support, I'm sure, is the only reason I didn't beg for an epidural." She had made an impression on others as well. Earlier in my pregnancy I had asked my doctor if he could recommend any doulas. He raised an eyebrow and said, "I can't help you." But the day after Bobby's birth, he asked for Aimee's business card. He wanted to have it on hand when the next patient asked for a doula.

As for Tim and me, we'll be using a doula again when our second child arrives this May. Aimee is not available -- she's just had her third baby -- but she has recommended a colleague. I'm sure we'll soon be just as grateful to her.

Related links:

Outside link: Doula information at

Outside link: Doulas of North America

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