The Essential Role of the Father (and a Doula) in Childbirth — “Let my people go!”

In the 1990s, I published a number of papers in the medical and birthing literature to help birthing families design and experience safer and more satisfying birthing experiences.

On of the articles I published was for a midwifery journal on the issue of whether the father of the baby should be in the delivery room or not  (Larimore WL. The Role of the Father in Childbirth. Midwifery Today. Issue No. 51, Autumn, 1999, 15-7).

Here’s the text of that original article:

During the late 1960s and the early 1970s, the earliest days of fathers’ involvement in childbirth in America, men were expected to be intimately involved as advisors, coaches and decision-makers for the woman (Simpkin, P., 1992).

However, experienced birth observers commented that few men seemed to be comfortably, confidently, and competently able to meet either the physical or the emotional needs of the woman in labor (Kierse, MJNC, et al., 1989).

Thus, the concept of the father as “birth coach” was increasingly reported to be impractical or unworkable and was therefore either abandoned or just tolerated by many prenatal instructors and L&D nurses (Simpkin, ibid).

The hope that the father would be an effective labor support companion failed to meet its hoped for potential for a number of complex but related reasons.

  1. Most men had virtually no knowledge of and certainly no experience with the birth process or obstetrical procedures;
  2. Many men did not want to be a labor coach (and there were women who resented being “coached”);
  3. Most men were unwilling or unable to ask doctors or nurses questions and seemed unwilling to serve as their partner’s birth advocate or ombudsman;
  4. Most men found it difficult to maintain confidence and perspective in a strange environment filled with busy, authoritative professionals;
  5. During the birth process, most men felt helpless, as they were unable to control the process or the outcome;
  6. Furthermore, as the birth process intensified, most men seemed to become more uncomfortable and to pull away from, not toward their partner;
  7. Men, in general, seemed to become distressed over witnessing the woman’s pain or discomfort; and
  8. Because of these and other reasons, most men were not able to provide the constant reassurance and nurturing that women need during the labor process.

Research has substantiated some of these anecdotal observations and may explain why most men appear to be ineffective birth companions—at least in the sense of positively effecting birth outcomes.

In general, the research done to date reveals that male partners play an important but minor role during labor and birth of most women.

In other words, when it comes to evidence-based medicine, having a man involved in the birth process is “better than nothing,” but not much! At least not nearly as helpful and effective as a female support companion.

The effect of male partners on the labor and birth process has been compared to the effect of trained and experienced female labor support persons (doulas) Clear differences in favor of the doula have been noted.

For example, first-time fathers touch their female partner in labor only 20 percent of the time compared to 95 percent for experienced doulas.

The study also found that male partners spent significantly less time with their laboring partners and were physically close to them for much less time than doulas (Bertsch TD, Nagashima-Whalen L, Dykeman S, Kennell JH, McGrath S. Labor support by first-time fathers: Direct observations with a comparison to experienced doulas. J Psychosom Obstet Gynecol 1990;11:251-60).

In addition, the behavior of first-time fathers has also been compared to female relations or friends of the laboring mother (untrained or “lay” doulas).

These studies also demonstrate that men do not appear to provide the same support as women.

Most male labor partners remain significantly farther from the laboring woman than females. When the laboring woman’s discomfort increases, the supporting women move closer to the laboring woman and the man moves back or away or even leaves the labor area.

It appears to me, as a male who has had the privilege to attend over 2,500 births, that it is time for male birth attendants to say to the birthing community, “Let my people go!”

For the most part my people (men) appear to not want to be there (at least all the time), are uncomfortable there (especially in the early active stage of labor), and want to be given the freedom and the permission to come and go.

It appears that there are reasons for birth attendants to learn how and when to use men in the birth process and when to “let them go”!

In addition to a woman’s almost intuitive desire and ability to effectively touch and nurture a laboring woman, the medical literature indicates that women supporting women during labor (at least when compared to male companions) seem to use more phrases of a specific, active, supportive nature.

Men tend to do more “general” talking. It appears that the birthing literature documents that women are able to more effectively communicate to women during labor and birth.

These data and observations, although true for most men, do not, of course, apply to all men.

Most male labor and birth partners (preferably the baby’s father) can play an essential role in providing support for most birthing women. Furthermore, a female partner or support person (doula) cannot make some of the unique contributions that the male partner can make, as the male partner may have a more intimate knowledge of the woman and love for her and her child (Kennell, J.H., 1991).

It is almost as if some men are able or gifted to be able to “turn on” or “activate” a more nurturing role during labor and delivery.

Nevertheless, the active and effective male support person during labor appears to constitute a small minority of male birth partners. This was demonstrated in one study, which described the man’s role in labor in one of three ways:

  1. The “Coach” – who actively assisted and led the woman in breathing and relaxation techniques and took responsibility for her management of labor.
  2. The “Teammate” – who followed suggestions from the woman or nurse as to what to do. The “teammate” took his lead from others and was “there to help.”
  3. The “Witness” – who viewed himself as a companion to “hold the woman’s hand,” to observe labor and to witness the birth.

In this report, 20 percent of the fathers were “coaches,” 20 percent were “teammates,” and 60 percent were “witnesses.”

The witness is the role that is least likely to make any difference in the birth – as far as outcomes.

Furthermore, and of much credit to their gender and much benefit to their laboring partners, the “witnesses” were most likely to recruit a woman to assist in labor support (Kierse et al., ibid).

Therefore, any expected positive effects upon birth outcomes by male support during labor may be overemphasized.

However, according to several studies, the male’s presence during labor and birth is still important to many women.

Furthermore, fathers appear to be able to provide more continuous support to a woman in labor than do most labor and delivery nurses: “In general, fathers were significantly more likely than nurses to be present in the labor room, to offer a comforting item, and to touch their partner” (Nicholson J, Gist NF, Klein RP, Standley K. Outcomes of father involvement in pregnancy and birth. Birth 1983;10:5-9).

In addition, mothers rate the father’s presence as significantly more helpful than that of the nurses and the father’s presence at the birth strongly increased the mother’s satisfaction with the birthing experience.

It is important to recognize the possibility that sometimes the presence of a man during the labor process can be disruptive or harmful to some women.

Some midwives have reported to me experiences in which the father actually disrupts the birth process.

For example, the cervix has been seen to “reform” or “constrict” in laboring women when a man enters the labor room.

Other midwives report to me that they have observed ‘arrest of labor’ or ‘labor dysfunction’ when a man enters the labor room.

These experienced and sensitive female birth attendants say that if the man’s relationship with the laboring woman has been marked by violence or abuse (or even if the laboring woman has been abused by other men), then these phenomena are even more likely.

These anecdotal observations need to be studied. Further research in this area would be very important for birth attendants.

Based upon the current birthing literature, it appears that there is no evidence of harm from allowing the father to be as actively involved during pregnancy and the birth process as he wishes to be and as his laboring partner wants him to be, despite the possible negative consequences to the labor process of having at least some men involved in the process. (Doulas of North America, 1998).

A midwife that I greatly admire spoke about the role of the father this way: “On the nascent fashion for fathers to attend the delivery of their offspring, Sheila Judge wrote: ‘Roll up for the greatest show on earth, come and view your baby’s birth! Blood, urine, sweat, and faecal matter, a great treat for a prospective pater’” (Midmer et al., 1995).

Over the last twenty years, the value of a woman supporting a woman before, during and after birth (the doula) has been firmly established in the medical literature.

Women supporting women in birth is, in my opinion, the most important and underutilized tool that maternity care providers can employ, and which fathers can insist upon, to keep labor normal.

The Cochrane Collaboration stated, “Thirteen trials, involving more than 4,900 women, were included in the Review. The continuous presence of a trained support person reduced the likelihood of medication for pain relief, operative vaginal delivery, Cesarean delivery, and a 5-minute Apgar score less than 7. Continuous support was also associated with a slight reduction in the length of labour. Five trials evaluated the effects of support on mothers’ views of their childbirth experiences; while the trials used different measures (overall satisfaction, feeling very tense during labour, failure to cope well during labour, finding labour to be worse than expected, and level of personal control during childbirth), in each trial the results favoured the group who had received continuous support.”

Another review stated, “. . . delivery units should routinely endeavor to provide continuous professional support in labour” (Seitchik, J. et al., 1987).

Yet, another review concludes, “There is no more cost-effective or simple strategy to improve the health of laboring women than using the doula” (Sosa, R. et al., 1980).

I would agree completely with John Kennell, MD, who said, “If a doula were a drug, it would be unethical not to use it.” (Kennell JH. Doulas: Into the mainstream of maternity care. Birth 1998;25:213-4)

The father who wants to attend his laboring partner’s birth without the assistance of one or more supportive women (doulas and a midwife) may be placing his desires above the best care available for his partner.

It is becoming increasingly apparent to me that the role of the doula and the father are in no way competitive and in many ways complementary.

With a doula present during and after the birth process, many inappropriate societal expectations and significant pressures are taken off of the father.

Female support persons allow the male to participate at his own comfort level and free him to enter and leave the labor and birth room(s) as desired.

In my experience, fathers usually feel relieved and de-stressed when they can rely on one or more doulas for help and guidance.

A partnership with doulas and midwives can allow a man to feel more significant, reduce his stress and discomfort, and allow him to enjoy the experience more fully.

For those fathers who want to and who can play a more active support role, the doula is still able to assist and guide him in effective ways to help his partner during and after labor and birth.

Can maternity care nurses provide continuous support? Usually they cannot.

One study of over 3,000 quarter-hour observation periods at a university hospital in Montreal found that 6.1 percent of nursing time was spent in activities including “physical comfort emotional support, instruction, and advocacy” (Gagnon AJ, Waghorn K.  Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth 1996;23:1-6).

Nearly 75 percent of the nurses’ time, across all shifts and days of the week, was spent outside the room of the parturient, suggesting “the need for perinatal caregivers and hospital administrators to reexamine how nurses spend their time, given the evidence from randomized trials showing the beneficial effects of continuous support on birth outcomes” (Gagnon AJ, Waghorn K.  Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth 1996;23:1-6).

A retrospective study at a large public hospital in the United States found that nulliparous patients cared for by nurses for the shortest amount of time prior to the birth (presumably resulting in less time to have “the doula effect”) had a 19% cesarean birth rate compared to only a 4.9%  for those nurses who spent the most time with the patient – no matter which physician was attending the case.

The likelihood of a normal labor and delivery was also increased in patients whose labor nurses were more likely to use a form to record psychosocial data than the nurses who were less likely to fill this out. The authors assumed that filling out this form was an indicator of nurses who spent more time with the patient (Radin, 1993).

Therefore, it appears that the maternity nurse can, if she chooses, be an effective part of the laboring woman’s effective support team.

Unfortunately, since most maternity care nurses appear to either be unable or unwilling to provide the continuous support that a birth mom needs, the responsibility to choose, empower and equip a continuous support team for pregnancy, labor, birth and the postpartum period appears to rest upon the birth mom and her male partner.

Caring and evidence-based birth attendants would appear to be well-served to assist a birth family in choosing such a support team.

One meta-analysis reported this: “Depending on the circumstances, ensuring the provision of continuous support may necessitate alterations in the current work activities of midwives and nurses, such that they are able to spend less time on ineffective activities and more time providing support” (Seitchik, J., ibid).

For many women, then, the ideal birthing support team may include the father of the baby, one or more close female friends or family members and the doula.

The doula should normally be present as an addition to, and not necessarily instead of, the male partner and female friends or family who the birth mom desires to have attend the birth.

Potentially, the doula, male partner, and supportive female friends or relatives may make the perfect team for the woman and her birth attendants (labor nurses, midwives, and/or physician). Each should complement the other’s strengths.

One meta-analysis recommended this: “Given the clear benefits and no known risks associated with intrapartum support, every effort should be made to ensure that all laboring women receive support, not only from those close to them but also from specially trained care givers (nurses, midwives, or lay women). This support should include continuous presence, the provision of hands on comfort, and encouragement” (Seitchik, ibid).

Based upon this review of the birthing literature, it appears reasonable for birth attendants, birth moms, and the male partner to all vigorously seek to recruit an active labor support team that could include female friends or family, a doula, and the father.

Also, based upon this literature, it would appear that birth attendants (midwives, family physicians and obstetricians) who fail to facilitate and encourage the formation of such a support team do so at their and their patients’ peril.

Recognizing the potential strengths and weakness of the father’s role along with the role the father desires during the birth process (coach, teammate or witness) will facilitate the effectiveness of the entire support team and the outcomes the birth family will experience.

Giving the father the freedom to be comfortable and the permission to participate (or NOT participate) in the birth process, as he desires, appears to be appropriate.

One of the most important roles that we prenatal and birth caretakers will ever have may be to encourage, empower and equip the father:

  1. to help organize and facilitate his partner’s female support team,
  2. to learn how to communicate more effectively with his partner, and
  3. to prepare for his critically essential purpose as father to the new child.

Here’s another blog series of mine you might enjoy, “How to Keep Normal Labor Normal”:

  1. Philosophy,
  2. Partners,
  3. Professionals,
  4. Pain control,
  5. Procedures,
  6. Patience,
  7. Preparation,
  8. Positions,
  9. Payment, and
  10. Prayer.
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3 Responses to The Essential Role of the Father (and a Doula) in Childbirth — “Let my people go!”

  1. Amy Romano says:

    Very thoughtful post – thank you! I’m going to share this one on Facebook. I wish it had been written before the recent Blog Carnival on labor support at the Lamaze blog! See http://www.scienceandsensibility.org/?p=839

  2. You might want to consider that the men are suffering from unconscious and unresolved memories of their own birth trauma (which includes circumcision) — and that these memories are activating during the birth process, making the men unable to be fully present, emotionally, mentally and psychically, with their partners. This is not a defect in men. This is a defect caused by technological birth and the amount of trauma men (and women) have had to endure.

    If men were given the opportunity to resolve their traumatic imprints/memories BEFORE birth, they would make much better birth partners.

  3. Also, the disempowerment men feel when another man (the all-knowing doctor) steps in and usurps the father’s role, is immense. This is not healthy for the relationship between him and his partner, and not healthy for the relationship with his child.

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