No pain, no gain.

Not necessarily.

The discomforts of pregnancy and the pain of labor fade the moment a mother cradles her newborn. Before then — and immediately after, when reality sets in — Mom needs all the help she can get.

She needs a doula.

Doula, in Greek, means woman servant. Historically, an experienced sister, mother, friend or grandmother became a birth coach who “served” the laboring woman.

Where are they now?

At work. Playing golf. Far away. Not interested.

“People hear ‘doula’ and think midwife or home birth without medication,” says Jenna Land.

She knew better.

Land’s mother, Daisey Maxey, is a doula who attended her daughter during pregnancy and 50-hour labor, in a hospital, with an epidural, supervised by an obstetrician.

“My mother didn’t take over,” Land says. “She helped me sort through the process and make a decision. She gave my husband confidence.”

“In our culture, nurturing traits are not being passed on,” Maxey says.

A review of the effects of continuous labor support in 21 trials involving 15,000 women showed a significant reduction in Caesarean and forceps deliveries, length of labor, requests for epidurals and narcotics.

Tammi Beers, an RN/nurse educator at Women’s Care Center, Pinehurst Surgical Clinic, concurs. She has referred patients — particularly military couples where the father is deployed — to doulas. Experience at a large birth center in New York taught Beers a doula’s value: “(The medical staff) embraced any positive energy. The more education patients have, the better.”

Doulas, by training, fall into two categories: Birth doulas provide prenatal education, are present during the entire labor and birth, help initiate breast-feeding, and bow out with a home visit. Postpartum doulas assist mother and infant, emotionally and physically, afterward. Some doulas hold both certifications.

DONA International, the world’s largest doula certification organization, has 7,000 members (up from 750 in 1994), including 162 in North Carolina but only a handful in Moore County.

“Other places doula is a common word — not here,” says practitioner Suzanne Clendenin.

Certification requires an intensive three-day workshop, completing a reading list and documenting at least three births. This on-the-job process may take two years.

Doula certification and practice are not regulated by law.

Four local doulas gathered recently to discuss their profession, methods and experiences. All are mothers. Two are grandmothers. They share an aura of calm, capability, confidence and caring.

The Doulas

Ashley Smithson and Amber Thomas, of Sandhills Doulas, formed in 2010, relate to their clients as contemporaries. Smithson, a former music teacher, is also a registered prenatal yoga instructor. Thomas noticed the lack of prenatal support groups in Moore County. She and Smithson expanded into prenatal yoga, then took doula training, mentored by Tammi Beers.

Daisey Maxey, of Pinehurst Doula Care, also a former music teacher and hospice worker, has assisted more than 110 births in North Carolina since earning certification in 2002.

Suzanne Clendenin, of Birthday Presence, realized the need while helping frightened young women, some with unsupportive or absent families, at Life Care Pregnancy Center, in Carthage. She has assisted 30 births in four years, all in hospital. Home births are uncommon in North Carolina; state law requires that midwives be RNs with midwifery certification and be underwritten by an MD.

Doula Dos and Dont’s

The doula-client relationship begins with an interview, preferably early in the pregnancy, ideally including the father. Discussion centers on educating the first-timer, revisiting previous birth experiences, exploring a birth plan. The doula explains her methods and the cost: about $500, no matter how long or difficult the labor.

“It has to be a good fit,” Maxey says.

Some women want massage, aromatherapy and relaxation techniques. Others prefer hand-holding and verbal encouragement.

“The doula does not speak for the mother,” Smithson says. “But the mother can talk through the doula,” Clendenin adds.

Although a doula recognizes each level of labor she does not perform medical procedures or offer medical advice. But, Clendenin says, “We know birth so well. I can look in a woman’s eyes and tell how many centimeters she’s dilated.”

However, Maxey continues, “We respect the doctor, let him or her call the shots. But we don’t back off. We’re quiet, whispering words of encouragement.”

Thomas observed that nurses monitor progress electronically from a central location supplemented by hands-on care as needed, whereas the doula does not leave her client’s side. She breathes and walks with her, plays music, administers cold packs, fetches drinks and ice chips.

“When a client hits the wall at 7-10 centimeters, I say yes, you’re throwing up, yes, you’re panicking, but that’s normal — and then, you’re home free,” Maxey adds.

A doula accompanies her client into the delivery room and in special circumstances, into the OR during a Caesarean section. She takes notes, which may include the music that was played and news of the day. These notes are converted into a birth story.

“The mothers love that,” Thomas says, since in the heat of the moment details are forgotten.

A doula integrates and mediates family dynamics to benefit the client. If too much is going on, she requests “quiet time” with the soon-to-be mother. A doula does not usurp or replace the husband/partner. In fact, she also becomes his support and source of information. At Thomas’ first birth the husband wanted to participate but was terrified.

“He just stood in the corner,” Thomas says.

“I always give him a job,” Clendenin adds. “Men like to do something.”

A study published in the Journal of Obstetric, Gynecologic and Neonatal Nursing reports that fathers are almost always too stressed and emotionally involved in the birth process to be good labor coaches.

Postpartum services may include child care, light housekeeping and referrals to community resources.

“That’s when the world stops,” Jenna Land says. “Everybody leaves. Your husband goes back to work. But your doula’s there.”

Sometimes, in an emergency situation, the doula must step back. Maxey recalls a client who had an amniotic embolism.

“In that case, the doula looks at the big picture,” she says. “The daddy had no one. My role was obvious.”

When complications arise, Maxey becomes the messenger communicating information to the family. For example, Maxey reassures a client requiring an unplanned Caesarean section.

“I tell her everything’s all right and she’ll be holding her baby in minutes,” she says. “This can be every bit as useful.”

What is not useful, the doulas agree, is the 45-minute triage period following hospital admission, when a laboring woman is separated from her doula and family.

“That startled me. It interrupts the continuous support that’s been going on for hours,” Smithson says.

Because mother-doula is a confidential partnership, “We have to vent to each other and talk about how we could have handled a situation better,” Smithson says.

Doula care is exhausting. Conflicts may arise with the family, medical staff or client herself.

“After some births, you say, I’ll never do this again,” Clendenin admits. But, Maxey adds, even if the birth has been horrendous, payback comes when the mother says, “I couldn’t have made it without you.’”

All things considered, “I can’t believe this is really a job,” Thomas says with a big smile.

The Clients

Doulas serve professional women, the spa set, desperate teenagers, single moms, military personnel and women with medical conditions that preclude anesthesia. Maxey has assisted nurses, doctors’ wives and lesbian couples. Some doulas work pro bono for extreme cases. Occasionally, a needy client will develop a dependency.

“We set limits, boundaries,” Clendenin says. “This has to be a well-defined relationship.”

Casey Barbera, a 30-year-old business owner and Thomas’ client, will deliver her first child in July. Barbera’s mother lives close by, but the baby’s father serves in the military. She learned of doula care through a midwife in Wilmington — also that the perception is changing. Barbera is uncertain which obstetrician will be on call.

“Having a child is a huge step for a woman. It’s stressful not to know who will deliver the baby,” Barbera says. “The doctor comes in when the baby is ready to be born, but a doula is there to deal with the nurses. She is another pair of hands.”

A Doctor on Doulas

Doctors can go either way. Much depends on the doula. A physician follows a patient’s wishes; doulas elsewhere have been criticized for attempting to influence their clients’ medical decisions. However, on May 3, a physician-authored paper titled “The Case for Including Doula Services in Obstetric Care for Underserved Women” was presented to the American College of Obstetrics and Gynecology’s annual meeting.

Dr. Stephen Szabo, of the Women’s Care Center at Pinehurst Surgical Clinic, observed doula care favorably during hundreds of deliveries at a military hospital, also with several patients at FirstHealth Moore Regional Hospital. Only one doula, encountered during his residency, “got in the way.”

“I’ve never had an issue here,” Szabo says. “Doulas calm and soothe new moms, explain the unknown. A patient needs a range of options — the more choices the better. We treat doulas with respect; they can be valuable members of the team.”

Poster Mom

Dana Kennedy will give birth to her first child, a boy, in June. Kennedy is an emergency room RN at FirstHealth Moore Regional Hospital. Dr. Szabo is her obstetrician. Ashley Smithson is her doula. Kennedy’s husband was deployed during part of her pregnancy.

Kennedy learned about doulas while living in Savannah. “Doulas are common there,” she says. “I was surprised when people here thought it was a hippie thing.”

Kennedy knew Smithson from pre-pregnancy yoga, graduated to her prenatal yoga class and retained her as a doula. They made a birth plan, which includes an epidural because, Kennedy says, as a nurse she’s seen the pain and fears it.

Kennedy’s husband is home now, ready to help and asking why they need a doula.

“This is my decision,” the confident mother-to-be replies. “Our families are in Texas and Illinois. I know what to expect. But this time, it’s me.”

Contact Deborah Salomon at debsalomon@nc.rr.com.