Alert level 2: Why you deserve a birth doula

In New Zealand we are currently at Alert level 2 of the Covid-19 pandemic. Due to the admirable effort of our ‘team of 5 million’ adhering to the lockdown restrictions, we have successfully moved out of level 4 lockdown through level 3 and now into level 2.

Under level 2, we have more freedom and are no longer confined to our bubbles. Businesses are resuming, children are returning to schools and ECEs and public facilities, such as cinemas, libraries and playgrounds, are re-opening for the enjoyment of all. As I type, bars are getting ready to open their doors for the first time since the start of level 4. Strict precautions such as contact tracing, physical distancing, and hand hygiene remain in place as we continue to keep the rest of New Zealand safe.

Also under alert level 2, social gatherings such as weddings, family events, religious services and private functions, like birthdays, can all take place (with up to 10 people). Up to 50 people can attend funerals and tangihanga. These are all significant cultural events and worthy of respect and the recognition they deserve.

But one particular important event is missing.

And that is Birth.

Birth, for many, is also a social (and cultural) gathering that draws people together in various capacities, and, in my opinion, is of equal importance to funerals, tangihanga, weddings, and is actually someone’s birthday too!

And yet disappointingly, birth has received no individualised, woman-centred or case-by-case consideration throughout the pandemic, despite some 5000 new babies (and new parents) being born under alert level 4.

Under Alert level 4 in NZ, women and birthing people were only able to have 1 support person with them during the birth (at hospital), and no support person at all on the postnatal ward.  As a birth doula, 3 Step Rewind practitioner (birth trauma recovery) and a mother, I stand alongside new parents grieving for the loss of their support (which many may have invested in from the beginning of pregnancy) and feel angry for the parents left traumatised by having their doulas or partners escorted out while at their most vulnerable. As a birth doula, I have had to inform multiple clients that I am no longer able to support them when they give birth; despite 9 months being spent building a meaningful connection and preparing for their birth experience.

I also understand that we are in unprecedented times and need to implement new policies and rules quickly. At the beginning, our goal was to get ahead of the virus and start to flatten the curve here in NZ. I also totally understand that initially there was insufficient data on Covid-19, making it difficult to base policies on evidence-based research. Our hospitals and birth centres were doing everything they could, and rightly so, to limit people coming through their corridors and therefore protect their staff and patients.

However, we are now under alert level 2. I am thrilled to say we are ahead of the curve and have more information about Covid-19. I therefore had strong hopes that, with the extra freedom level 2 brings, the same level of consideration would be given to birth in terms of the number of support people allowed on the delivery suite.

There is a reasonable amount of evidence around the importance of having a dedicated birth companion for women and birthing people during childbirth. This could be the birthing person’s partner, friend, doula or medical professional.

The World Health Organization (WHO) recommend birth companions in four of their guidelines World Health Organization 2012World Health Organization 2014bWorld Health Organization 2015World Health Organization 2018.

A Cochrane qualitative evidence synthesis carried out in 2019, which complements a previous Cochrane review published in 2017, explored the effect of continuous support for women during childbirth.  The results of these reviews concluded that if a woman/birthing person has continuous support during childbirth, which means having someone there the whole time, both mothers and babies are statistically more likely to have better outcomes. This review analysed 51 studies from 22 countries, which showed that labour companions played numerous important roles in supporting women. Birthing partners provide informational support with regards to the process of childbirth, supporting communication between medical staff and women. They also offer practical support, encouraging women to be mobile and find comfortable positions, providing emotional support and non-pharmacological pain management in the form of massage and meditation. Often, birth partners act as advocates for the women, speaking up in support of her and her wishes. Birth partners also help women feel in control and build their confidence through praise, reassurance, and continuous physical presence. It’s worth taking note that most of the studies in the review included the perspectives of having a male and/or female lay birth partner. Only four of the studies focused on the perspectives of healthcare providers, like midwives and nurses, being the only birth partner. What is quite clear from all studies is that the absence of a birth partner contributed to women’s feelings of disempowerment, fear, and loneliness throughout labour and childbirth (Bohren 2015a; Shakibazadeh 2018).


Does it matter who the birth partner is?
As we have already established, having a birth partner makes a difference to women and birthing people.

Sadly in some countries, there is currently a blanket ban on all support people, which could potentially lead to an increase in all those areas that we see statistical differences.

Here in NZ we are very fortunate to have one of the leading models of maternity care, on a global level, due to the continuity of care provided by LMC (Lead Maternity Carer) midwives. This does not mean however that a birth partner is superfluous. A birth partner is ‘as well as’ not ‘instead of’! A birthing person can never feel ‘too’ supported. In actual fact, given the dire working conditions of our LMC midwives, exacerbated by the pandemic, it means the birthing person has greater choice and greater support in a time of crisis, which can only be a good thing. Professional, cohesive and collaborative practice between an LMC and a birth partner results in working together for the good of the birthing person; enabling them to feel fully supported.

Interestingly, the Cochrane review was able to look at six outcomes and document the difference a birth partner made in these areas: use of any pain medication, use of artificial oxytocin during labour, spontaneous vaginal birth, caesarean births, the baby’s admission to special care nursery after birth, and negative birth experiences.

Two out of the six outcomes showed the best results when the support was provided by a doula – someone who was not a member of the hospital staff member and who was not part of the woman’s social network. The researchers found that overall, women or birthing people who have continuous support during childbirth experience a:

  • 25% decrease in the chance of a caesarean birth; if the birth partner was a doula it was a 39% decrease
  • 8% increase in the likelihood of a spontaneous vaginal birth; if the birth partner was a doula 15% increase
  • 10% decrease in the use of any pain medication
  • Shorter labours, on average by 41 minutes
  • 38% decrease in the baby’s risk of a low five minute Apgar score
  • 31% decrease in the risk of being dissatisfied with the birth experience; mothers’ risk of being dissatisfied with the birth experience was reduced with continuous support provided by a doula or someone in their social network (family or friend), but not hospital staff

These statistics are clearly showing that preventing birth partners for women and birthing people could potentially give them a birth experience that is negative, increase the risk of their baby needing special care and increasing the risks of major stomach surgery.

There are increasing numbers of families all over NZ choosing to invest in themselves and their birth experience by hiring a self-employed birth doula (literally translated means ‘woman who serves’).  Yet interestingly, despite the growing demand for doulas in NZ by parents themselves, the history of, and the evidence behind the role, there has been no reference to the existence of doulas as a complementary and optional component to the NZ maternity system.

What does the law say?

Interestingly, Birthrights, a charity in the UK that champions respectful care for women during pregnancy and childbirth by protecting human rights, explains:

“The legal position is that restricting the number of birth partners is an interference with a woman’s right to a private and family life under Article 8 of the European Convention on Human Rights. NHS Trusts are permitted to limit or interfere with Article 8 rights, but only if such an interference is lawful, necessary and reasonable (proportionate).  They must also ensure that any interference with the right is not discriminatory against certain groups of people who would feel the impact of the restriction even more severely (else it could also be a breach of Article 14 of the ECHR).” 

“NHS Trusts that restrict a woman’s right to choose who will be present at her birth, for example by restricting birth partners to one, will need to be very clear that this response is proportionate to the additional threat of infection from Covid-19. They will also need to be very clear that it is an equally appropriate restriction in every single individual case.”

“Even if a Trust feels confident that its response is proportionate, we strongly advise that it should look at exceptions on a case by case basis, as a blanket policy could be open to legal challenge. Such a legal challenge could include the point that the blanket policy is not only disproportionate but is discriminating against certain groups of people who will feel the impact of that interference with their Article 8 rights much more severely.  Examples of such groups could include people with significant, existing, mental health issues, physical disabilities or more disadvantaged groups.”

What could the impact be on fathers and partners?

The birth of a baby is clearly a very important moment for both mothers and fathers. It’s not only a baby that is born, the mother and father is born too. Bearing witness to the birth of a baby impacts on attachment and bonding. We know from research that men who were supporting their female partner felt that it had a positive impact on them as individuals (Kululanga 2012Sapkota 2012).

They also felt that supporting their partner in labour and seeing them give birth, positively impacted on their relationship, as well as in the way they bonded with their baby. When the father or partner was able to share the experience of their baby’s birth, it increased their love and respect for their partner, and they were able to connect with to the baby from the moment of birth (Dodou 2014Kululanga 2012Sapkota 2012).

In summary, the evidence points to improved outcomes for women and birthing people as well as their partner by having a birth doula present. I had hoped, now being under Alert level 2 and the freedom this allows, that further consideration would have been given to weigh up the risks and benefits of allowing an additional person, such as a doula, to the delivery suite. I appreciate that it is not an easy time for policy makers, pregnant women/people and their families. We don’t know what the real impact of Coronavirus is going to be here in NZ. I just hope that the restrictions and limitations that have been set in place for women and birthing people under level 4, and continuing into level 2, don’t have more of a harmful effect on the bigger picture, than the actual virus itself here in NZ.

Posted by Anna Driver

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