Doulas seek regulation to avoid conflicts with doctors

A bill (PL 3.946/21) is being discussed in the Chamber of Deputies that tries to guarantee the presence of doulas in the delivery rooms in the country, professionals hired by pregnant women to provide emotional support. The proposal was approved by the Senate, in March last year, and now awaits a vote in the Chamber of Deputies. According to the approved text, the presence of doulas will be assured in any type of delivery, being able to integrate the teams of basic health care.

The proposal is met with resistance by physicians who fear undue interference by doulas in functions of the medical and nursing team, responsible for defining the best procedure for the mother and the birth of the baby. On the other hand, many pregnant women, afraid of suffering “obstetric violence” (a term criticized by the CFM for stigmatizing medical practice), would like these doulas to be present at these times.

If the project is approved, to be a doula, you will need to have a high school diploma and a specific professional qualification in “doula”, in courses lasting at least 120 hours. According to Senator Mailza Gomes (PP-AC), author of the project, the role of the doula will not be to replace family care and assistance from health professionals, but to bridge the gap between the pregnant woman and the health team. For her, the performance of doulas can bring comfort to mothers, with the use of non-pharmacological techniques that help relieve pain and favor labor.

Concerns of obstetricians

The Brazilian Federation of Gynecology and Obstetrics (Febrasgo) advocates a broader discussion by society before advancing the proposal. The entity recalls that it is necessary to have technical knowledge to accompany a birth and that the regulation of doulas could popularize procedures at home, a place that is unprepared to provide all the necessary security for the birth of a new life. Other health agents also add, among the worrying points, the insistence of doulas to perform a normal delivery, which is not always possible, in addition to questionable suggestions when there are complications, in the heat of the moment, often putting pregnant women against doctors.

Mirela Foresti, a member of the Febrasgo committee, believes that, in order not to jeopardize labor, it is necessary to accurately discriminate what the doulas’ duties will be. “Is this person going to be part of the institution, is he going to be hired by hospitals and how will the limits of this person’s performance be defined? She cannot prescribe medication, she cannot deliver. She will only be responsible for monitoring and providing support and cannot interfere with the act of people who are giving birth, such as the obstetrician. You have to have an organization [de funções] for this to work in order to improve the well-being of the patient”, says the gynecologist.

In defense of the regulation and performance of these professionals, Marilda Castro, doula and perinatal educator, postgraduate in education and public health and president of the Association of Doulas of the Federal District, says that there are still prejudices in relation to this profession that need to be overcome for the sake of pregnant women. “Doulas do not perform any type of obstetric assistance. Doula does not deliver. A doula does not check the mother’s dilation or blood pressure, nor does she listen to the baby’s heartbeat, ”she explains.

According to her, doulas have taken on an important role in supporting mothers and also in rescuing the importance of normal delivery, which is avoided by many physicians because it requires more time to work, not always with proportional remuneration.

For doctors like Elisabeth Kipman, gynecologist and obstetrician, “the role of doulas can be very good and important because they can transmit security and support to pregnant women”. However, she highlights the importance of assertive regulation to avoid conflicts with the doctor who is performing the delivery. “The doctor should not be treated as an ignorant killer by the doula, and this often happens, because the doula kind of dominates at the time, making the pregnant woman revolt against the doctor”, says the doctor.

Kipman also points out that some doulas are influenced by ideological courses, which in the name of “women’s self-affirmation” do not always defend the best practices. “There is an activism that grew with the participation of doulas and this is harmful. I believe that it has to be a regulated function, just as the doctor has to be open to the issue of humanized childbirth. The doula has to be a doula, companion, affective and face-to-face support, but she cannot interfere in the medical and nurse conduct”, she reinforces.

Regarding home births, accompanied by doulas at home, Febrasgo warns of the risks of complications without the presence of health professionals or adequate medical equipment.

“Birth starts with low risks, but it can quickly get worse and, being far from the hospital environment, this care for the worsening situation may not be quickly attended to. We defend childbirth care focused on safety and this happens within the hospital environment”, reinforces Foresti.

Why women seek doulas

The work of doulas in Brazil dates back to the 1970s, but began to gain more notoriety in the 2000s, with the completion of the first doula certification course. Despite the resistance of some health professionals, many women have resorted to this service, with the consent of doctors who are not opposed to the practice.

This was the case of Natally Antelo, mother of a 5-month-old baby, Natally Antelo, who decided to have a doula accompany her as soon as she found out she was pregnant. She says that she felt safer having a doula on her side as she was a first-time mother. “It was a very good experience, it gave strength to me and my husband. And she followed us from the beginning until the time of delivery, which was normal and uneventful,” she said.

Nataly also said that she received all explanations about the types of delivery and baby care, as well as breathing techniques for the baby’s expulsive period. “If everyone could, they would hire a doula, they bring affection, affection and a lot of security. You know it’s going to be all right because she’s there to help,” she says.

Doula Renata Cordova found out about doulage in 2015, through a friend, and decided to combine nursing with this follow-up. She has been on this mission for almost 10 years, she says she has accompanied many exciting births and this year alone, she is already assisting 5 pregnant women. “As a nurse, we see a technical side and as a doula we see it with a different look, especially the passion and emotion that exists between the parents’ encounter with the baby”, she says.

State laws allow the work of doulas

Due to the increase in demand and without a national regulation for the work of doulas, some states began to create state laws authorizing the entry of these professionals in maternity hospitals, birth centers and similar hospital establishments, in public and private networks.

The Brazilian states that, until then, sanctioned this norm are: Rio de Janeiro, Goiás, Mato Grosso, Mato Grosso do Sul, Rio Grande do Norte, Amazonas, Alagoas, Pernambuco, Ceará, Tocantins, Amapá, Rondônia, Santa Catarina and the Federal District.

All these states recognize the role of doula according to the definition of the Brazilian Classification of Occupations (CBO): “birth companions freely chosen by pregnant women and parturients, who aim to provide continuous support to pregnant women in the pregnancy-puerperal cycle, favoring the evolution of childbirth and well-being of the pregnant woman”.

By state law, the professional can accompany the pregnant woman throughout the period of labor, delivery and immediate postpartum; with authorization from the parturient and certification of a course for occupational training in this area. The professional is not authorized to perform medical or clinical procedures, as well as nursing procedures, unless she has this training duly certified.

In the state of Goiás, for example, it has been determined that restricting or prohibiting the entry, circulation or exercise of professional activities by doulas in public and private health institutions can lead to punishments for the establishment, which include a warning and, if a repeat offender, a fine with values ​​between BRL 1,600 and BRL 16 thousand.

The World Health Organization (WHO) and the Ministry of Health of several countries, including Brazil, recognize and encourage the work of these professionals. International studies show that the presence, support and techniques taught by doulas can also reduce the use of analgesia by 17%, the use of oxytocin by 31% and the need for a cesarean section by 28%, for example.

To become law, the project needs to be approved by the Commissions for the Defense of Women’s Rights; of Social Security and Family; Labor, Administration and Public Service; and Constitution and Justice and Citizenship. Then it will go to the Plenary, and if approved, it will be sanctioned by the President of the Republic.