In the last century our culture has stepped off the path of healthy birth, leaving most women lacking trust in their bodies and assuming that pregnancy and "delivery" are medical events that require procedures and drugs.  The result has been a hospital-based "standard American birth" that includes a variety of interventions large and small, many not proven to help at all—and some proven to harm. 

The move from home births to hospitals in the early 20th century meant that the support of other women was left behind.  Without mothers, sisters, friends or partners, birthing women in hospitals were supported only by nurses—who could not usually provide the continuous presence that eases the birth process.  In our time

partners, and even friends and relatives, were finally allowed into the hospital birth room—but without some experience of birth and a calm, accepting attitude about its challenges, they cannot usually provide steadfast encouragement and reassurance.

Many women have a difficult time giving birth; so women and their doctors have turned to drugs and procedures in an effort to make labor easier, faster, and safer. (These interventions also served obstetricians' goals of differentiating their profession from midwifery.)  Meanwhile continuous support from another woman has been shown in many studies to have just these effects—even if the woman is untrained in labor support and does nothing but keep the mother company throughout the labor.

Enter the doula, at once an ancient and a new idea.  Doulas are non-medical professionals who provide continuous physical, emotional, and informational support throughout labor.  They have knowledge and experience that parents, especially first-time parents, often don't have.  A doula does not have what partners, friends, and relatives do have—a close personal relationship with the mother—but she strives to develop a close working relationship prenatally that respects and protects a woman's individuality and her choices.  Ideally, this relationship is between the doula and the mother and partner, rather than just between the doula and mother. 

As part of that relationship, a doula helps the mother and partner determine their wishes for the birth and helps identify issues that might interfere with those wishes. She encourages the couple to learn, to prepare, and to be confident and trust in the birth process. Her further work flows from the couple's needs and requests.  She often suggests ways the couple can research issues, negotiate with caregivers, and ultimately take responsibility for their birth, rather than leaving it in the hands of others. Sometimes the working relationship centers around information, sometimes around negotiation strategies and understanding OBs and hospitals, and sometimes around the mother's emotional needs or the birth needs of mother versus partner.  Couples usually benefit greatly from this kind of prenatal preparation.  Thus much of the doula's most important work is often done before labor begins.

Once labor starts and the client(s) summon her, the doula provides support until an hour or more after the birth, whether in the hospital or elsewhere.  This continuous support is often impossible for a nurse; not only does the doula stay on through shift changes, but unlike a nurse she focuses on the woman and her subjective experience without the competing responsibilities of charting and adjusting machinery.  Here, too, sharing her knowledge of labor and birth can do a lot to reassure and calm her clients, and lowering a birthing mother's anxiety level helps labor progress more smoothly. 

But just as important in reducing anxiety is emotional support.  Many mothers do not get enough encouragement and confidence from their partners, because those partners are also facing the intensity of labor for the first time.  Childbirth classes cannot usually prepare a partner to provide as much support as the mother may need, especially in a long, unusual, or complicated labor.  A doula can fill in any gaps with encouragement, confidence in the mother's abilities, praise, and attention to what birth environment the mother needs. A calm, dim, untrafficked room that provides the mother with a sense of privacy and safety can give her the freedom to follow her instincts to a better birth.  This is hard to achieve in a hospital, but a doula's experience and knowledge of what environmental factors facilitate labor help a lot.

A doula is also skilled at important physical support and comfort measures. These include massage, sacral counterpressure, direction and encouragement in relaxation and breathing, positioning suggestions based on the course of labor and the mother's comfort, reminders to drink and pee, use of the birth ball and rebozo, and whatever else seems to help the mother—as long as it is non-medical in nature and does not interfere with medical care.  If a partner is present at the birth, ideally a doula will encourage and help the partner provide this support rather than do it all herself.  Doulas are careful to not usurp the partner's role, but rather to facilitate the partner's desire to help and participate as much as he/she wants. 

A doula's overall responsibility, no matter what skills and information she calls on to fulfill it, is to help a mother and partner have a birth that brings them joy rather than anger, strengthens rather than diminishes them, improves their relationship, and gives them confidence for the parenting ahead rather than planting doubts as to their adequacy. 

Ideally the work of a doula will result in a more natural, less interventive birth that is easier on the mother; more than fourteen randomized controlled trials have shown various positive effects of doula care.  The effects of a doula include shorter labors, fewer requests for pain medication including epidurals, fewer complications, less use of oxytocin/Pitocin  (a commonly used drug that makes labor harder and more dangerous for mother and baby). Caeserean sections and forceps use are less common with doula care; mothers show less postpartum depression and are more satisfied with their babies and their birth experiences.  Babies of doula-attended births have even been shown to have shorter stays in the hospital and less need for special care. 

The doula's job is not to do any one thing in specific, but to do whatever is necessary within her scope of practice to "hold the space" for birth to unfold the way the parents want it to.  The doula must remember that it is not her birth, and ask herself at each turn "how will the mother remember this?"  Doulas protect the memories of birth for the parents, and can thus improve overall outcome for mother, partner, and baby no matter what events occur during the birth.

A birth in which the mother can be in her power is a candle flame threatened by many breezes: distrust of the birth process, anxiety and fear, and medical intervention.  The doula is the hand cupped steadfastly around that flame.