Doulas : Birth and Death

Megan Markle, Duchess of Sussex, is reputed to have engaged a doula as a support person for the birth of Archie on 6 May 2019. This was not viewed with favour by a senior UK obstetrician, Professor Tim Draycott, who was concerned about the obstetric risks of a 37year-old mother in labour.

In recent times doulas offer their services for the antenatal, intrapartum, and postnatal care of women, mostly from the middle classes, who can afford the out of pocket expense involved. In the US, the costs of an obstetric doula range from $USD 600-2500 ($A 840-3500) and in Australia the costs range from $A 800 to $2000 for a confinement. The COVID 19 pandemic which has caused severe limitations on spousal and family presence in labour wards has led to an increase in demands for home birth and doula assistance.

Case Report:

A 27-year-old woman engaged a doula to accompany her to her third delivery at a metropolitan hospital. She had successfully delivered her second child vaginally after a primary Caesarean section. Her antenatal care was largely conducted by her GP with only one visit to the Hospital at 34 weeks. In labour the patient refused to be examined even abdominally and attempts to record the fetal heart rate were rejected. She spent much of her short labour on all fours. The doula supported the patient in her several refusals questioning the necessity of all the recommendations made by the midwives. When finally persuaded to undergo a vaginal examination which the Registrar was required to perform on all fours, she found the patient had a breech presentation, and the foetal heart was profoundly slow. An emergency Caesarean section followed at which time it was found that the baby was stillborn, and the uterus had ruptured. Obstetric staff felt frustrated that their best efforts to provide safe labour care were rejected by the patient aided and abetted by her doula.

History

The emergence of birth doulas in the 1960's coincided with cultural shifts in many countries whereby husbands and other relatives were finally permitted to accompany mothers into labour wards. One might well ask why it was necessary then to employ doulas when similar non-medically trained support persons were finally available to provide emotional and physical support in labour. Part of the answer might relate to the large numbers of single and married women who lack reliable family support. Partners may be often unable to adopt a supportive role because of their own fears or discomfort in such a female-centred activity as childbirth. Spouses may also find it difficult to be objective in their support for a loved one experiencing severe pain.

One study suggested that at least half of women felt that the birth doula was more helpful than their partner . That may reflect the effect of professional education on doulas emphasising close physical contact, verbal encouragement and a constant presence in labour. There has been some research looking at the alternative of midwifery close support in labour however the beneficial results of reduced pain medication, shorter labours and less intervention found with doula support have not been reproduced using midwives Just how continuous psychological support in labour reduces rates of intervention is unclear but it could include doula support for patient refusals to accept well-intentioned obstetric advice. The outcome for mothers and babies from such reduced rates of intervention also remains uncertain. A paper recently published by Beale and Petros, 2020 suggests that reduced rates of intervention associated with prolonged second stages of labour may come at the cost of a much higher rate of obstetric anal sphincter injuries (8% vs 1. 7%).

In South Australia a coronial inquiry into the death of 3 babies under the care of the same ex-registered midwife prompted an amendment to the Act whereby it became prohibited for unregistered practitioners to attend homebirths in the absence of a registered midwife or registered medical practitioner. The maximum penalty for failure to comply with this provision is $A30,000 or imprisonment for 12months. Other Australian states and territories have enacted similar amendments. Some midwives have chosen to function as doula-equivalents either because they were compulsorily deregistered or chose to allow their registration to lapse. The Australian College of Midwives believe that such unregistered practitioners -otherwise termed Unregistered Birth Workers (UBW) pose a risk to women and their babies because of inadequate training or antipathetic views against conventional medical care Under the Health Practitioner National Law s113 a doula who is not a registered midwife is prohibited as misrepresenting herself/himself as a midwife.

Death Doulas

The stated functions of Death Doulas include: advance care planning, wills, legal guardianship Information; navigating the medical system; coordinating complementary therapies; advocacy and education; spiritual support;  support other carers; assisting clients to create memories and legacies; planning living wakes; death education; home-based death; sudden death; care of the body after death; assistance with funeral planning and pastoral care.

Whilst the support of a death doula may fill deficiencies in palliative care of dying patients the lack of regulation and standardised training have been identified as significant issues which diminish the standing and function of death doulas in the community. A particular issue would arise if a death doula were persuaded to criminally assist with active voluntary euthanasia. Another aspect with potential legal implications might be if a death doula became a recent beneficiary of a dying patient's last will and testament. Coercion or manipulation of a person in relation to their will is often very difficult to substantiate.

Doula is a historic term for a woman servant or slave. Originally these were captive women from the pre-Mycenean era in Greece and its environs who, as an act of grace were spared and allocated to the women of the victorious nation as helpers or personal assistants. In former times they would perform household tasks in childcare, cooking, cleaning and emotionally support new mothers. Debate exists as to whether the term doula is appropriate for the current concept of a woman who attends to the emotional and physical needs of a labouring woman or dying person mostly in return for financial gain.

NSW Regulations for Unregistered Health Providers.

The NSW Health Minister under the power of the Public Health Act 1991 (NSW) established a Code of Conduct for unregistered health providers . The key elements of that Code of Conduct include practising in a safe and ethical manner, avoiding unwarranted claims to cure serious disease or illness, freely permitting consultation with registered medical practitioners, respecting the informed choices of their clients, avoiding financial exploitation of clients, avoiding misinformation of clients, respecting privacy of clients and maintaining contemporary records of client encounters. The powers of the NSW Health Care Complaints Commission (HCCC) have also been extended to allow investigation and imposition of sanctions (such as conditions or prohibition from practice) on health practitioners who are not registered (Health Care Complaints Commission Act 1993 (NSW), ). The NSW HCC has the power to issue an order prohibiting a person from providing health services for a period of time;  issue an order placing conditions on the provision of health services and provide a warning to the public about a practitioner and his or her services. The NSW scheme lies between a self-regulated system and a statutory registration scheme.

Further Reading

Lloyd S. Baby boomers are hiring death doulas and aiming for the grave on their own terms (ABC News, Sydney 1 March 2019); Rawlings, D. et al. "The voices of death doulas about their role in end-of-life care." Health & social care in the community (2019): 12-2128(1); http://www.lawreform.vic.gov.au/sites/default/files/Succession_Laws_final_report.pdf

Victorian Law Reform Commission. Succession Laws August 2013