It’s no surprise that over the past few decades, the cesarean section (“C-Section”) surgery rate has increased by almost 60% in the United States, reaching 32.9% in 2009 up from 20.7% in 1996[1]. Unfortunately, efforts to lower the rate of cesareans have had little impact.

A study of the ARRIVE TRIAL released on February 1, 2018, showed that low-risk pregnant patients who were induced at 39 weeks gestational age, had a lower mother and baby complication rate and a lowered cesarean section rate.

However, Rebecca Decker from “Evidence-Based Birth” shared a startling statistic; it took 28 women to be induced at 39 weeks to prevent one cesarean whereas it took only nine doulas to attend nine births to avoid one cesarean.

The healthcare costs saved by introducing labor support persons, such as doulas and midwives, cannot be understated. Before medicine became institutionalized, midwives and nurse-midwives were the norm and are still essential healthcare providers especially in underserved regions all over the world.

What is a Doula?

A doula is a “trained professional who provides continuous physical, emotional and informational support to a mother before, during and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible.”[2]

Doulas do not perform deliveries, but obstetricians and midwives can perform deliveries. The difference between midwives and obstetricians is that C-sections, forceps, and vacuum deliveries can only be performed by obstetricians.

What is a Midwife?

A midwife is a trained, qualified professional who enables pregnant women to deliver naturally.

According to The World Health Organization (WHO), a midwife is:

“A person who, having been regularly admitted to a midwifery educational program that is fully recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery, and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. The educational program may be an apprenticeship, a formal university program, or a combination.“

Types of midwives include Certified nurse-midwife (CNM), certified professional midwife (CPM), direct-entry midwife (DEM), registered midwife (RM), licensed midwife (LM), depending on the availability of state licensure for non-nurse midwives.

What is the difference between a Midwife and a Doula?

The primary difference between a doula and a midwife is that a doula has no medical training and can only provide guidance, assistance, and support in a non-medical capacity whereas a midwife helps pregnant women in the delivery of her baby vaginally.

A birth doula offers relaxation and breathing technique support, as well as massages and other comforting services, and helps with labor positions. A doula is not a substitute for a life partner at birth. Instead, doulas encourage participation and offer support for the partner.

Whereas, a midwife is trained to evaluate and recognize emergencies and may consult with an obstetrician if there is a concern. Midwives handle healthy, uncomplicated pregnancies. Many physician practices employ nurse-midwives in their practices.[3]

Although home-based deliveries account for a small percentage of all births, home-based births jumped 29 percent between 2004 and 2009. Mary Lawlor who is the executive director of the National Association of Certified Professional Midwives (CPM) reported that CPMs “go out into underserved communities, where the women live, where there aren’t other providers, and provide community-based care for them.”[4]

What services do Midwives and Doulas provide?

The type of support services that doulas and midwives offer to pregnant women include a wide range of educational materials primarily centered around healthy eating and the physical changes that surround the pregnancy and birthing processes.

Because the increased nutritional demands of pregnancy are not well established for many micronutrients and cannot be remedied by increased caloric intake alone, a doula or midwife’s advice can become essential in ensuring the proper amount of nutrients are consumed.

A doula or midwife knows the patient best and understands that nutrient requirements during pregnancy are often calculated based on erroneous beliefs that only the metabolism of the baby and mother coupled with the mother’s incremental weight gain are the only factors impacting nutrient needs.

This approach may not factor in the changes in absorption and excretion that occur during pregnancy. For instance, kidney function is increased by 40% which raises the excretion of water-soluble nutrients such as Vitamin C and Folate.[5] In addition, Zinc levels decline progressively during pregnancy, whereas magnesium starts its decline in late pregnancy. It is estimated that eighty percent of all people are magnesium deficient.[6]

A doula or midwife would be able to determine the proper nutrition and advise or corrective measures to help aid a mother to optimal nutrition levels during pregnancy, leading up to birth, and even after delivery for recovery.

Together, patients can discuss the role of micronutrient supplementation on the health and well-being of both mother and infant. Entering the last few weeks of pregnancy, healing and recovery supplements like HealFast has the potential to improve stamina, reduce injury and promote healing.

Nutritional Requirements during Pregnancy

Water-soluble nutrients:

1. The RDA for vitamin C in pregnant women is 67% higher than that for non-pregnant and nonlactating women (WHO).

2. Thiamine dietary allowances are 12% higher in early pregnancy due to increased requirements and remain higher throughout [7]

3. Riboflavin dietary allowances are 7% higher because of increased maternal and fetal tissue synthesis and a small increase in energy utilization.[8]

4. Niacin dietary allowances are 10% higher for similar reasons.[8]

5. Vitamin B-6 deficiency rarely occurs; but because it is not stored in the body's tissues and due to the increased needs in the second half of pregnancy. Because vitamin B-6 is not stored in the pregnancy, the IOM (35) has recommended that the RDA be increased by 46% to ensure sufficient amounts during pregnancy.[9]

6. Folate: Besides the need for folate before conception, dietary folate allowances during pregnancy increase by 147% (FAO 1988) to build or maintain maternal stores and to meet the needs of rapidly growing maternal and fetal tissues.[10]

7. Vitamin B-12: The FAO/WHO recommends a 40% increase in the vitamin B-12 dietary allowance to meet fetal and metabolic needs.

Fat-soluble nutrients:

Regarding fat-soluble nutrients during pregnancy;

1. Vitamin D needs to increase 300%,

2. Vitamin A increases 20%,

3. Vitamin E increases 25%. Note: Vitamin E and K are nontoxic in adults even at high doses but should be stopped prior to surgery or delivery for blood thinning purposes.

Conclusion

Education is the essential tool practitioners need to provide in the healthcare setting.

Midwives and doulas are uniquely qualified and able to fill this role in any medical environment, both during labor and throughout pregnancy. Physicians and nurses welcome their participation on practically every level.

When selecting a doula or midwife, the most important criteria is your interpersonal interaction and connection with the person after you carefully discuss your individual preferences and needs.

Citations:

1. Martin et al. 2011

2. https://www.dona.org/what-is-a-doula/

3. Medicinenet.com

4. https://www.huffingtonpost.com/michelle-chen/home-birth_b_1247867.html

5. https://academic.oup.com/ajcn/article/72/1/280S/4729670

6. Keirse, unpublished observations, 2000

7. Heller et al. 1974.

8. FAO/WHO 1985.

9. Institute of Medicine 1998

10. (IOM 1998)

References:

Food and Agriculture Organization (FOA) of the United Nations, World Health Organization. (1985) .

Requirements of vitamin A, thiamin, riboflavin, and niacin. Report of a Joint FAO/WHO Expert Group. Rome: FAO.

Food and Agriculture Organization (FAO)( 1988)of the United Nations, World Health Organization.

Requirements for vitamin A, iron, folate, and vitamin B-12. Report of a Joint FAO/WHO Expert Consultation. Rome: FAO.

Heller S, Salkeld RM, Korner WF. (1974) Vitamin B1 status in pregnancy. Am J Clin Nutr:27:1221-4

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Institute of Medicine (IOM). (1998)Dietary reference intakes.Thiamin, riboflavin, niacin, vitamin B-6, folate, vitamin B-12, pantothenic acid, biotin, and choline. Washington, DC: National Academy Press, prepublication edition)

Martin JA, Hamilton BE, Ventura SJ, et al.( 2011) Births: Final data. National vital statistics reports; vol 62 no 1. Hyattsville, MD: National Center for Health Statistics.

World Health Organization (WHO) (1974) Handbook of nutritional requirements. Geneva: WHO.