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Enabling Doula Support in Japanese Society

The 74th Child Science Symposium entitled "Doula support in affluent society: Who should be a doula? Where are they needed?" was held at Konan Women's University on December 5, 2010. Dr. Noboru Kobayashi was the key speaker, and I was privileged to accompany him as a panelist. I would like to summarize the presentations here. Both of the presentations was uploaded in the Journal of Child Studies (http://www.crn.or.jp/KONANWU/bulletin/vol.13/74_KOBAYASHI.pdf) in March 2011 in the Japanese language.

In the 1970s, when Dr. Kobayashi was going back and forth between Japan and Europe on business with the International Pediatric Association, he happened to encounter the book "Tender Gift: Breastfeeding" written by an American medical anthropologist Dr. Dana Raphael at a book store in London. In the book Dr. Raphael introduced the concept of a doula, theorizing that there have been systems of mutual assistance for childbearing women all around the world, even among animals such as dolphins and elephants. The term "doula" means 'woman's servant'and comes from Ancient Greek. Since the 1990s, countries have been developing not only the concept of doulas but also developing it as a new occupation. Doulas provide non-medical, in particular emotional, support for women and their families before, during, and after childbirth.

Dr. Kobayashi found the book significant and translated it into Japanese. However, the concept was too new for Japanese people to appreciate at a time when their society was experiencing high economic growth and turning its focus toward materialism and mammonism. The translated version has since gone out of print.

Dr. Kobayashi set up and introduced a theory of Trinitarianism of the human brain: the most primitive brain of basic survival (diencephalon, brain stem, and spinal cord), the primitive mammalian brain of vitality (paleocortex and limbic cortex), and the higher mammalian brain of living skillfully (neocortex). The first one is responsible for the basic bodily functions, the second one for instincts and emotion, and the third one for intellect and logic. He claims that tender emotional support by doulas is attributed to the second one; therefore, it is essential in order for human beings to live robustly and even serves as the root of higher brain functions. As Japanese society became overly convenient, individualistic, and materialistic, people may not have had to develop or exercise the instinctual/emotional brain programs. Dr. Kobayashi claims that doula support is needed in developed societies in order to address shallow interpersonal relationships and the social problems they produce. He has referred often to Dr. Raphael's remark that anyone can be a doula.

After Dr. Kobayashi's presentation, I, as a nurse-midwife and researcher, added the following: Every mother hopes that she and her baby will live healthy lives. According to the World Health Organization definition, health is not only about physical states without disease or injury but also about emotional, spiritual, and social well-being (1948). They are not independent of each other but are interrelated. In modern medicalized childbirth settings, obstetrics defines and controls what health should be for mothers and babies. In addition, highly institutionalized hospital systems require paperwork, procedures, and self-defending attitudes in order to prevent lawsuits. As a result, maternal health care providers, even nurse-midwives, are forced to prioritize medical work and can spare less time and attention on direct care for their clients. Less time is able to be spent on simply being with and listening to clients in an attempt to initiate intimate or creative relationships with them. Ironically, it is precisely this lack of humanistic communication between providers and clients that may lead to additional conflicts and lawsuits. Clients who give birth in hospitals pay fees for perinatal care, but this fee is for medical tasks only. Emotional support is not tangible; therefore, it is not paid for or recognized in medicalized childbirth settings. Accordingly, when providers are too busy, emotional work can be easily omitted. To make the matter more complex, it is merely up to a provider's awareness and consciousness whether or not she values such invisible work. (Even if a provider seems to be very nice to you, it is unknown where her kindness comes from: the help may be from her genuine caring or she may treat you well according to a routine customer manual because she or the hospital is afraid you may sue otherwise, or both. That difference would not matter in casual daily settings, but what about during one of the most sensitive times in your life? Wouldn't genuineness matter?)

Both for positive and negative reasons, emotional support is not paid; in other words, holistic health cannot be obtained through medicine only or through the current maternal health care system. Health cannot be purchased with money. Non-medical support, i.e., doula support, should be encouraged now, so that mothers and their babies can be truly healthy in current society. Doula support is not a luxury but an essential or ethical part of perinatal care. If health care providers recognize the necessity and effectiveness of doula support but are too busy to guarantee it to their clients, they are, as professionals in maternity health care, responsible for looking for alternative ways to ensure that every woman and her family can receive it.

Numerous research studies have shown the effectiveness of doula support in the last three decades. Inspired and supported by Dr. Raphael's work in anthropology, Drs. Kennel and Klaus initiated randomized clinical trials with a more refined research design (Sosa et al, 1980), and many researchers around the globe followed their lead. Recently, the most generalizable findings on the effectiveness of doula support have been provided through systematic reviews (meta-analyses) such as by Cochrane Library Review (Hodnett et al., 2009). The process is well illustrated in the pyramid of evidence (Sackett et al, 2000: http://guides.lib.uchicago.edu/content.php?pid=84176&sid=1404787; Hujoel, 2008: http://download.journals.elsevierhealth.com/pdfs/journals/1532-3382/PIIS1532338208001140.pdf) which shows how scientific knowledge is refined over time.

According to the latest Cochrane review (Hodnett et al., 2011), effects of doula support include: shorter labor, more natural childbirth with less medical interventions such as cesarean section, more favorable condition of the newborn and better outcomes at birth, and greater reported satisfaction of mothers with their childbirth experience than women who did not have doula support. Because the effectiveness of doulas has become incontrovertible, clinical trials to examine the effects of doula support should decrease from this point on, since deliberately assigning childbearing women to a control group (i.e., a group of women with no doula support) would be ethically problematic, considering that women of all ages and cultures have been supported by experienced women in their childbirth event. The first stage in doula research has been accomplished. What should the second stage be? The mechanism of doula support still seems to be unknown. More qualitative and quantitative research studies are describing who doulas are and how doula support or programs should be implemented. The field of doula support will be controlled by doulas themselves, instead of researchers.

Some symposium participants raised questions: The necessity of doula support is understandable and agreeable. However, why is such support not recognized? What can we do? The following were my suggestions:

In order to increase people's awareness, you can offer help when you see a person in pain or suffering. Role modeling such actions and practices is the key to doula support and is called mothering the mother. Let's increase the number of aware people one by one, remembering the words of Dr. Margaret Mead who was Dr. Raphael's teacher: "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. "

Additionally, preparing "Doula Fact Sheets" in Japanese may be helpful, because knowledge is important to support people's appropriate decision-making. Although detailed literature reviews have been done in Japanese in the Doula Laboratory (http://www.blog.crn.or.jp/lab/03/) since 2005, a shorter version would be more convenient for many people.

Moreover, let's find and acknowledge doulas and get connected. It does not matter whether or not the word doula is actually used. They may be for- or non-profit. There are some doula movements that exist in Japan already, such as "Doula Club" for mothers in Nara prefecture, "Mothers' Attendant Project" in Kyushu Birth Center, and "Postpartum Doula Service" by Japan Babysitter Service. In the "DV Doula" project (PI: Professor Hiroko Tomoda), DV (Domestic Violence) survivors' needs as well as the possibility of them becoming future doulas is being explored.

Since the East Japan Earthquake on March 11, the Japanese people as well as the media and experts have emphasized the importance of emotional support for people at high risk. Not only traditional top-down approaches but also bottom-up approaches by lay people are making huge differences and are recognized by people in the affected areas. Support and knowledge from foreign countries have given much encouragement and hope to the Japanese people. Is there any way to incorporate doula support information into the reconstruction process of the country in the short and long term? Hopefully, the out-of-print Japanese translated book "Tender gift: Breastfeeding" translated by Dr. Kobayashi will be reproduced, and many Japanese people will have a chance to learn tips from this classic book on doula support.


Acknowledgement
I am especially grateful to Professor Nobuo Isshiki for his coordination of the symposium and to Ms. Keiko Kishimoto for her excellent work in writing an article in Sankei Newspaper (December 15, 2010). I am very grateful to all researchers and doulas who have developed the knowledge base on doula support.


Reference
Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2009) Continuous Support for Women during Childbirth. Cochrane Database of Systematic Reviews. Issue 1.

Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2011) Continuous Support for Women during Childbirth. Cochrane Database of Systematic Reviews. Issue 4.

Scott, K.D., Berkowitz, G., & Klaus, M. (1999). A comparison of intermittent and continuous support during labor: a meta-analysis. American Journal of Obstetrics & Gynecology, 180 (5),1054-9.

Sosa, R., Kennell, J., Klaus, M., Robertson, S. &, Urrutia, J. (1980). The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New England Journal of Medicine, 303 (11), 597-600.

Zhang, J., Bernasko, J.W., Leybovich, E., Fahs, M., & Hatch, M.C. (1996). Continuous labor support from labor attendant for primiparous women: a meta-analysis. Obstetrics & Gynecology, 88 (4 Pt 2), 739-44.
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