Several memorable events have been instrumental in the development of my interest in the doula phenomenon.
The first one took place in February 1980, when Marshall Klaus visited us in the Pithiviers hospital (near Paris). He found it notable that six midwives, a group of help nurses, and I (as the only doctor) could cope with 1000 births a year. He told me about the randomised, controlled trial he was conducting in Guatemala with John Kennell (and others) about the presence of a female companion. He was not yet using the term doula, which appeared in a September 1980 publication (Sosa et al. 1980). We shared our comments on this study, emphasizing that it was useful in the context of the USA.
The second event took place in June 1998, when I was asked to do information sessions for doulas in London. I immediately noticed that most women participating in such sessions were radically different from those who had received an official European midwifery degree—almost always in their early 20s. These were mature women—most of them mothers or grandmothers—with a huge experience of life. I realised that, even in Europe, some pregnant women felt the need to rely on the same experienced mother-figure before, during, and after the birth. Liliana Lammers (who had had three homebirths in my presence) came to the first session. In December 2002, when she had acquired sufficient practical experience, we decided to cooperate and to complement each other in a renewed kind of information session. This was an opportunity to reconsider the dominant vocabulary. We eliminated the word training, which is too suggestive of an active role. We preceded the word doula (which originally meant “female slave”) by paramana, a term that means “next to the mother” and was acceptable to the Greek community (and those, like me, who had studied the Greek language).
The third event took place more than five hours east of Moscow by plane, in Krasnoyarsk, where I was invited to participate in the launching of the Siberian doula association, in September 2013. Since that time, I find it impossible to ignore that the doula phenomenon is global. When an unexpected phenomenon becomes suddenly global, two questions must be raised: “What does it mean?” and “What about the future?”
What Does It Mean?
Until now the usual interpretations had subjective bases. Many pregnant women have expressed their feeling that the current health systems—whether public or private, and whatever the country—cannot ideally satisfy their needs. At a time when the generation gap is deeper than ever, and in the age of nuclear or one-parent families, some women look for substitutes for their own mothers during the period surrounding birth.
This is precisely the phase of our history when a scientific language can easily describe the physiological continuity between the end of pregnancy, parturition, and the interaction between mother and newborn baby. However, it is not by following the chronological order that we shall best appreciate the continuity. It is relevant to focus first on the particularities of human birth, before considering the end of pregnancy and the postpartum period.
Today, by presenting the concept of neocortical inhibition as a point of departure, the main particularities of human parturition are easily interpreted. Until recently, the gigantic and powerful neocortex was usually considered a tool at the service of vital physiological functions, providing information on space and time and facilitating communication. With the fast development of neurophysiology, it is suddenly easier to understand that, in specific situations, neocortical activity can, on the contrary, inhibit vital functions. This is the case, for example, of the sense of smell: When we moderate our neocortical control by drinking a glass of wine, we reinforce our sense of smell (Endevelt-Shapira et al. 2014). This is also the case with the birth process. It is as if, in certain circumstances, the tool becomes the master.
In the current scientific context, it is urgent to challenge the dominant interpretations of the difficulties of human births. It is commonplace to focus on mechanical factors. This perspective does not explain why, occasionally, women who are not morphologically special give birth easily within minutes, while others need a cesarean after long hours of hard labour. Such an enormous discrepancy is explained through the concept of neocortical inhibition.
This concept is a key to understanding the solution nature found to make human birth possible and even potentially easy. It is a simple solution: The neocortex must reduce its activity. Even during the twenty-first century, after thousands of years of socialisation of childbirth, there are still some women and health professionals who can easily interpret this solution. They know that when a woman can give birth easily by herself, without any pharmacological assistance, there is a time when she is cutting herself off from our world, forgetting what she had been taught, forgetting her plans, and behaving in a way that usually would be considered unacceptable for a civilised woman—for example, screaming or swearing. Some women can find themselves in the most unexpected, bizarre, often mammalian, primitive, quadrupedal postures. Interestingly there are anecdotes of women in hard labour complaining of odours that nobody else could perceive: This is an eloquent symptom of the kind of reduced neocortical control that appears as the prerequisite for easy birth among humans.
When this solution that nature found is understood, it becomes easy to analyse and summarise the basic needs of a labouring woman: A labouring woman needs to feel protected against all possible stimulations of her neocortex. The keyword is protection.
This is an opportunity to recall that the main stimulants of neocortical activity are well-identified, particularly language: Silence is a basic need. The effects of light on the birth process have not been taken seriously until recently, when it appeared that melatonin, the “darkness hormone,” is an essential birth hormone. This is why it is worth focusing on this factor. Studies of the interactions between melatonin and other brain mediators offer a promising avenue for research. The effects of melatonin as an inhibitor of neocortical activity are already well understood (Wang et al. 2003). In the age of artificial lights, the reasons to improve our understanding of melatonin release and melatonin properties are obvious. It is already well established that short wavelength light (in practice “blue” light) is the most melatonin-suppressive. It is also precisely the kind of light usually provided by the lamps in conventional delivery rooms (Gwinner et al. 2017). In a few words, let us just recall that any attention-enhancing situation is a stimulant of neocortical activity. Feeling observed and perceiving a possible danger are typical examples of such situations.
Until recently, the concept of neocortical activity and the importance of the keyword protection have been ill-digested notions. This is a reason why there has been a tendency to ignore that the spectacular brain cataclysm associated with the birth process is prepared during the weeks preceding the central event.
It has been noticed for ages that, at the end of their pregnancies, many women are not as mentally sharp as usual. They mention anecdotes of memory loss. Their topics of interest become different. Their needs for socialisation may be reduced and reoriented. They tend to restrict or to avoid all kinds of socialisation that are not related to their “primary maternal preoccupation.” Empiric knowledge is confirmed by scientific evaluations of deficits of several kinds of memory, particularly “prospective memory,” which is the capacity to remember to perform an action at the right time (Rendell and Henry 2008). It is usual to provide some advice to “combat” this condition and to reduce its “severity”: Take vitamins, have more exercise, drink plenty of fluids, rebalance your diet, etc. Another aspect of this “physiological preparation” is a reinforced sense of smell occasionally noticed by pregnant women. By using magnetic resonance imaging (MRI) techniques, a joint Spanish and Dutch team has clearly demonstrated that the end of pregnancy is associated with reductions in grey matter volumes, particularly in brain regions involved in social processes (Hoekzema et al. 2017).
The publication of such a study is symbolic of a turning point with huge practical implications. It reveals a physiological continuity. It suggests that before giving birth women need to live in peace and to feel protected against useless stimulations in the field of rationality. In our hospital in France, while singing together around the piano, pregnant women were not reading informative books or following classes….
There is also a tendency to ignore that after giving birth women can remain for hours, and even days, in a specific state of consciousness. In this framework, it would be worth studying in depth what is called “motherese,”—a simplified and repetitive type of language, with exaggerated intonation and rhythm, used by mothers when speaking to their newborn babies. And what about the roots of the universal lullabies? After giving birth, women need to remain “on another planet” for a while and, therefore, to feel protected against distractions.
After describing the physiological continuity between the end of pregnancy, parturition, and the phase of interaction between mother and newborn baby, we are in a position to offer interpretations of the doula phenomenon. In terms of needs during the whole period surrounding birth, “protection” remains constantly the central concept. Since the mother is the prototype of the protective person, it appears only natural that some modern women feel the need to rely on the same mother figure before, during, and after giving birth.
What about the Future?
Several scenarios are both possible and plausible.
According to the most optimistic one, the doula phenomenon will be transitory, after successful participation in a paradigm shift. One can imagine that a new awareness will suddenly have the power to reverse the increasing tendency to classify the midwife as a highly specialized technician trained to follow protocols (Odent 2005). A renewed vocabulary, with the keyword protection, will be symptomatic of an actual new way of thinking.
According to the most pessimistic scenario, neither fast-developing branches of physiology nor the doula phenomenon will have the power to reverse thousands of years of conditioning. The dominant disempowering vocabulary will not radically evolve and will go on suggesting that during the period surrounding birth a woman needs the active participation of the cultural milieu: helping, guiding, controlling, coaching, managing, supporting, etc. The term protection will remain ignored.
Then the doula phenomenon will be a missed opportunity.
- Endevelt-Shapira, Y, et al. 2014. “Disinhibition of Olfaction: Human Olfactory Performance Improves Following Low Levels of Alcohol.” Behav Brain Res 272: 66–74. doi: 10.1016/j.bbr.2014.06.024.
- Gwinner, C, et al. 2017. “Influence de la Lumière Sur le Processus de Parturition Humaine.” La Revue Sage-Femme 16(5): 303–23.
- Hoekzema, E, et al. 2017. “Pregnancy Leads to Long-lasting Changes in Human Brain Structure.” Nat Neurosci 20(2): 287–96. doi: 10.1038/nn.4458.
- Odent, M. 2005. “Can the Art of Midwifery Survive Protocols?” Midwifery Today Int Midwife (73): 12.
- Rendell, PG, and JD Henry. 2008. “Prospective-Memory Functioning Is Affected during Pregnancy and Postpartum.” J Clin Exp Neuropsychology 30(8): 913–19. doi: 10.1080/13803390701874379.
- Sosa, R, et al. 1980. “The Effect of a Supportive Companion on Perinatal Problems, Length of Labor, and Mother-Infant Interaction.” N Engl J Med 303(11): 597–600.
- Wang F, et al. 2003. “The GABA(A) Receptor Mediates the Hypnotic Activity of Melatonin in Rats.” Pharmacol Biochem Behav 74(3): 573–78.