By Clare Murphy
BBC News Health reporter
Continuous support may cut the need for an epidural, but the jury is still out
Increasing numbers of pregnant women are hiring doulas - paid birthing assistants who can hold a hand and mop a brow during labour. Are they an important addition or another must-have accessory in the lucrative business of pregnancy and birth?
They boast celebrity endorsement, with stars such as actress Nicole Kidman revealing that she had employed such an assistant at the birth of her child last year.
But one doctor would like to see more debate about the role of these women, who have no medical training and whose work is at present unregulated by an outside body.
Writing online in the British Medical Journal, anaesthetist Dr Abhijoy Chakladar says doulas are taking over roles that midwives should be performing and may even be compromising care by disrupting the relationship between the medical team and mother and affecting clinical decisions.
ALL ABOUT DOULAS
Doula is derived from the Greek for a 'woman of service'
Used in its present context since 1976
Popular in the US, where there are about 100,000 doula-assisted births a year
Currently about 1,000 doulas in the UK
Doulas offer emotional support during labour and will carry out a variety of tasks postnatally
Costs anywhere between £400 and £900 for antenatal, labour and postnatal package
The trend towards hiring doulas - who number more than 1,000 in the UK today - may, he said, "be a sad reflection of failures in the delivery of medical and midwifery care, a sticking plaster concealing greater problems."
But equally, he added, "a cynic might ask whether the doula business is actually necessary or whether it is exploiting - for profit - unspoken fears about NHS perinatal care and the seemingly limitless market for birth related products and service."
He describes one scenario where a mother did not follow his advice to shift position to improve the effectiveness of the anaesthetic he had just administered after the doula declared the mother was quite comfortable as she was.
"In this clinical situation the presence of the doula swayed the decision-making incorrectly," he wrote.
"Both the mother and father were confident and articulate, so I couldn't help but wonder why they needed to pay for support."
Overstepped or overstretched
In fact there seems broad consensus that doulas are indeed stepping in to provide the support that midwives do not provide - either because they are overstretched or because they have no relationship with a mother they have never met before.
While many mothers describe the support of their doula as invaluable, midwives themselves report mixed experiences - with some grateful for the extra help and others disconcerted by instances of aggressive or obstructive behaviour.
"Maternity services are seeing rapidly rising birthrates, increasingly complex births and midwife shortages. The pressure of work that midwives are facing means that too often they simply do not have the time to provide the kind of emotional support that doulas are offering," says Louise Silverton, deputy general secretary of the Royal College of Midwives.
"It is important that at local level midwives, doctors and doulas establish clear relationships and understandings about their respective roles. The woman and her baby is the focus of midwives' care, and whoever the woman chooses as her birth partner should work in harmony with midwives to ensure a safe and comfortable environment for the woman."
But she added: "Let me be clear about one thing, doulas should not interfere in any way in clinical decision making."
Jean Birtles, head of British Doulas, says there are birthing assistants who may be doing just that.
"This is a problem. The bottom line is that you do not interfere in any way, but unfortunately there are women coming into this field who have very little training and no real code of ethics. It is not her job to challenge the doctors or influence the mother one way or another, but to support her.
"There are moves afoot to set up a council which would regulate the work of doulas and that would be very welcome indeed. But let's not forget that many doulas are providing much needed, high quality support, patching up the gaps in midwifery care. In an ideal world we wouldn't need them, but until midwife numbers are up to scratch they are an important source of assistance."
With prices anywhere between £400 and £900 for a package that includes antenatal, labour and postnatal vists, doulas are on the whole a port of call for those with cash to spare.
But the NHS is also putting nearly £300,000 into rolling out volunteer doula centres across the UK to support isolated women with little help to hand. The network Doula UK also runs a hardship fund for poorer families.
Part of the interest in doulas is driven by the move towards promoting what are described as "normal" births - vaginal deliveries without pain-relieving epidurals - and away from expensive Caesarean sections. Analysis by the respected Cochrane Collaboration found an association between continuous support in labour and a reduced need for pain relief or a C-section.
However, whether doulas do in fact decrease interventions remains a moot point, as it is possible that the kind of women who are very determined to achieve a "normal" birth are more likely to hire a doula than those who do not see medicalised childbirth as a problem.
The issues surrounding the relationship between doulas and clinicians are part of a broader discussion about how polarised the childbirth debate has become, according to Dr Chakladar.
"As anaesthetists we don't come into work thinking 'how many needles can we stick in today'. Doctors are not the enemy but we are sometimes portrayed as such," he told the BBC.
"It's been pointed out that in no other field of life or medicine would you allow anyone to endure the pain that women endure in childbirth. And yet somehow women now feel failures if they have an epidural, or they end up having an instrumental or Caesarean birth.
"It's high time for a more balanced debate."