Editor’s Note: Ana Paula Markel is the Director of International Development for DONA International, a certified birth doula and birth doula trainer, and certified childbirth educator based in Los Angelos, California, USA. She has provided this statement from DONA International in response to the recent report from Spain’s General Nursing Council. — AG

DONA International is a non-profit organization of doulas that strives to train and educate each of our doulas to provide the highest quality and standard of care for birth and/or postpartum support to birthing women and their families. We promote continuing education for doulas and provide a strong communication link among and between doulas, families and the medical birthing community. Our membership exceeds 6,500 doulas in 50 different countries.

DONA International upholds strong guidelines for doulas with its Standards of Practice and Code of Ethics, maintaining that doulas are non-medical support professionals for families in the childbearing year.

DONA International would like to take a stand against the “Informed Doulas Report” from the Consejo General de Enfermeria (General Nursing Council) in Spain. The report and website contain serious and untrue allegations against the profession of labor support (doulas) that are considered defamatory and untrue, and falsely accuses doulas of engaging in harmful practices.

DONA International has been in touch with The European Doula Association and understands that at no point were they consulted; neither were any Spanish doula organizations nor parents or medical professionals who have worked with doulas. It also appears that the Consejo General de Enfermeria either did not examine or take into consideration various medical publications and studies about the benefits of labor support.

The true role of the doula:
A doula is a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth, or one who provides emotional and practical support during the postpartum period. Studies have shown that when doulas attend births, labors are shorter with fewer complications, and babies are healthier and breastfeed more easily. Evidence shows that the quality services of a postpartum doula can ease the transition that comes with the addition of a baby to a family, improve parental satisfaction and reduce the risk of mood disorders.

A Birth Doula:
• Recognizes birth as a key experience the mother will remember all her life
• Understands the physiology of birth and the emotional needs of a woman in labor
• Assists the woman in preparing for and carrying out her plans for birth
• Stays with the woman throughout the labor
• Provides emotional support, physical comfort measures and an objective viewpoint, in addition to helping the woman get the information she needs to make informed decisions
• Facilitates communication between the laboring woman, her partner and her clinical care providers
• Perceives her role as nurturing and protecting the woman’s memory of the birth experience
• Allows the woman’s partner to participate at his/her comfort level

Numerous clinical studies have found that a doula’s presence at birth:
• Tends to result in shorter labors with fewer complications
• Reduces negative feelings about one’s childbirth experience
• Reduces the need for synthetic oxytocin, forceps or vacuum extraction, and cesarean
• Reduces the mother’s request for pain medication and/or epidurals

A birth doula certified by DONA International is designated by the credentials CD(DONA).

A Postpartum Doula:
• Offers education, companionship and nonjudgmental support during the postpartum period
• Assists with newborn care, family adjustment, meal preparation and light household tidying
• Offers evidence-based information on infant feeding, emotional and physical recovery from birth, infant soothing and coping skills for new parents, and makes appropriate referrals when necessary

Research shows parents who receive postpartum support:
• Feel more secure and cared for
• Are more successful in adapting to new family dynamics
• Have greater success with breastfeeding
• Have greater self-confidence
• Have less postpartum depression
• Have lower incidence of abuse

A postpartum doula certified by DONA International is designated by the credentials PCD(DONA).

Doulas support families from all ethnic, religious and social backgrounds globally.

Women have complex needs during childbirth and the weeks that follow. In addition to medical care and the love and companionship provided by their partners, women need consistent, continuous reassurance, comfort, encouragement and respect. They need individualized care based on their circumstances and preferences.

DONA International doulas are educated and experienced in childbirth and the postpartum period. They are prepared to provide physical (non-medical), emotional and informational support to women and their partners during labor and birth, as well as to families in the weeks following childbirth. They offer a comforting touch that makes childbearing women and families feel nurtured and cared for.

Furthermore, the 2013 Cochrane Review on continuous support for women during childbirth concluded that “all women should have continuous support during labour. Continuous support from a person who is present solely to provide support, is not a member of the woman’s social network, is experienced in providing labour support, and has at least a modest amount of training [i.e. a doula], appears to be most beneficial.” (Hodnett et al, 2013)

The 2012 commentary by The World Health Organization Reproductive Health Library “Continuous support for women during childbirth” states, “Considering all the advantages and possible lower costs to the health system associated with the presence of a doula (less likelihood of cesarean sections and analgesia use), covering the cost of doula services should be considered by policy-makers.”

The European Convention on Human Rights offers protection to all individuals making choices in childbirth. In recent cases, the courts have asserted that Article 8 of the Convention protects women’s right to decide the circumstances and location in which they give birth. Women should never have any medical procedure performed without consent, should be able to decline unwanted interventions, however minor they may seem to staff, and should always be provided with sufficient, objective and unbiased information to make an informed choice. In extreme cases, disrespectful treatment during childbirth may also violate Article 3 of the Convention which relates to cruel, inhuman or degrading treatment.

For decades, DONA International has been collaborating with medical professionals in a supportive and productive fashion. In fact, in January of 2014, the American Congress of Obstetricians and Gynecologists released a statement, in which they endorsed doula care.

DONA International also understands that there are incidents, as in any profession, where individuals may not represent the profession well or properly, and for that, we have a formal grievance process to examine such cases, when needed.

In conclusion, DONA International encourages The Consejo General de Enfermeria of Spain to remove the report and the associated website, and to conduct a proper, evidence-based study. DONA International would like to volunteer its assistance in this effort.



European Doula Network: Response to the Consejo General de Enfermería (General Nursing Council, Spain) ‘Dossier de prensa – La verdad sobre las doulas

DONA International Position Paper: The Birth Doula’s Contribution to Modern Maternity Care, 2012

DONA International Position Paper: The Postpartum Doula’s Role in Maternity Care, 2012

Hodnett, ED, et al. “Continuous Support for Women during Childbirth (Review),” 2012

WHO Reproductive Health Library, “Continuous Support for Women during Childbirth.

European Convention on Human Rights

ACOG Obstetric Care Consensus. “Safe Prevention of the Primary Cesarean Delivery.”