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Am Fam Physician. 2004;70(3):448

to the editor: I would like to respond to the article and editorial on managing labor pain that appeared in the September 15, 2003, issue of American Family Physician. The authors of the article1 appropriately defined maternal satisfaction (which is not necessarily 100 percent pain relief) along with stressing the value of labor support. However, in the editorial,2 the authors state that “few women are afforded this option (of a doula and continuous labor support).”

Most physicians are not familiar enough with the concept of doulas to fully understand their role, where to find one, or how to recommend them to their patients. The two largest professional certifying organizations of doulas in North America are Doulas of North America (DO NA, and Childbirth and Postpartum Professional Association (CAPPA, These organizations maintain online directories of certified doulas by geographic area and current evidence-based research of the benefits of having a doula present during labor.

Experienced doulas charge between $50 and $900 per birth, depending on experience, geographic area, demand, patient's needs, traveling time, and sliding scale. Without knowing the “doula climate” in one's area, it is presumptive to insist that patients cannot afford the labor support. A requirement to become certified is three “certification” births. These are done without the expectation of monetary payment. It is beneficial to the physician and the patient to find out through DO NA and CAPPA who is pursuing certification in their area for patients who may not be able to afford a doula. There also is a program, Operation Special Delivery ( that supports the United States military by providing free doula services during wartime to women who are preparing for and giving birth while their partners are on military deployment.

Physicians should not dismiss the value of recommending certified doulas to their patients based on a preconceived difficulty of obtaining one. The authors of the article clearly stated: “Continuous labor support provided by a doula, a lay woman trained in labor support, consistently has decreased the use of obstetric interventions…. Fewer women had unsatisfactory birth experiences.”1

I also would like to stress the significance of recommending a certified doula or one pursuing certification if you are not familiar with the doula's skills, because anyone can call themselves a doula (friends, sisters, and other relatives). Referring to a doula as a lay woman should not be confused with “lack of credentials.” Birth experience, physician references, and formal training are required to become certified as a doula. Continuing education also is required to maintain certification.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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