It is common for women who undergo caesarean section to have reduced or absent bowel movements for hours to days.  During this time, women may experience abdominal cramps, nausea and vomiting. This usually resolves without treatment. [ 94 ]  Poorly controlled pain following non-emergent caesarean section occurs in between 13% and 78% of women. [ 95 ]  Following caesarean delivery, complementary and alternative therapies (e.g.,  acupuncture ) may help to relieve pain, though evidence supporting the efficacy of such treatments is extremely limited. [ 96 ]  Abdominal, wound and back pain can continue for months after a caesarean section.  Non-steroidal anti-inflammatory drugs  can be helpful. [ 36 ]  For the first couple of weeks after a caesarean, women should avoid lifting anything heavier than their baby. To minimize pain during breastfeeding, women should experiment with different breastfeeding holds including the football hold and side-lying hold. [ 97 ]  Women who have had a caesarean are more likely to experience pain that interferes with their usual activities than women who have vaginal births, although by six months there is generally no longer a difference. [ 98 ]  Pain during sexual intercourse is less likely than after vaginal birth; by six months there is no difference. [ 36 ]


There may be a somewhat higher incidence of postnatal depression in the first weeks after childbirth for women who have caesarean sections, but this difference does not persist. [ 36 ]  Some women who have had caesarean sections, especially emergency caesareans, experience  post-traumatic stress disorder . [ 36 ]


A woman who undergoes caesarean section has 18.3% chance of chronic surgical pain at three months and 6.8% chance of surgical pain at 12 months. [ 99 ]


In recent meta-analyses, caesarean section has been associated to a lower risk of urinary incontinence and pelvic organ prolapse compared to vaginal delivery. [ 100 ] [ 101 ]  Women who have vaginal births, after a previous caesarean, are more than twice as likely to subsequently have pelvic floor surgery as those who have another caesarean. [ 102 ] [ 103 ]


Global rates of caesarean section are increasing. [ 25 ]  It doubled from 2003 to 2018 to reach 21%, and is increasing annually by 4%. The trend towards increasing rates is particularly strong in middle and high income countries. [ 104 ] : 101   In southern Africa, the cesarean rate is less than 5%; while the rate is almost 60% in some parts of Latin America. [ 105 ]  The Canadian rate was 26% in 2005–2006. [ 106 ]  Australia has a high caesarean section rate, at 31% in 2007. [ 107 ]  At one time a rate of 10% to 15% was thought to be ideal; [ 4 ]  a rate of 19% may result in better outcomes. [ 8 ]  The World Health Organization officially withdrew its previous recommendation of a 15% C-section rate in June 2010. Their official statement read, "There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them." [ 108 ]


More than 50 nations have rates greater than 27%. Another 45 countries have rates less than 7.5%. [ 8 ]  There are efforts to both improve access to and reduce the use of C-section. [ 8 ]  Globally, 1% of all caesarean deliveries are carried out without medical need. Overall, the caesarean section rate was 25.7% for 2004–2008. [ 109 ] [ 110 ]


There is no significant difference in caesarean rates when comparing midwife continuity care to conventional fragmented care. [ 111 ]  More emergency caesareans—about 66%—are performed during the day rather than the night. [ 112 ]


The rate has risen to 46% in  China  and to levels of 25% and above in many Asian, European and Latin American countries. [ 113 ]  In Brazil and Iran the caesarean section rate is greater than 40%. [ 114 ]  Brazil has one of the highest caesarean section rates in the world, with rates in the public sector of 35–45%, and 80–90% in the private sector. [ 115 ]


Across Europe, there are differences between countries: in Italy the caesarean section rate is 40%, while in the  Nordic countries  it is 14%. [ 116 ]  In the United Kingdom, in 2008, the rate was 24%. [ 117 ]  In Ireland the rate was 26.1% in 2009. [ 118 ]


In Italy, the incidence of caesarean sections is particularly high, although it varies from region to region. [ 119 ]  In  Campania , 60% of 2008 births reportedly occurred via caesarean sections. [ 120 ]  In the  Rome  region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics. [ 121 ] [ 122 ]


In the United States, cesarean deliveries began rising in the 1960s and started becoming routine in the 1960s and 1970s. [ 104 ] : 101


In the United States the rate of C-section is around 33%, varying from 23% to 40% depending on the state. [ 3 ]  One of three women who gave birth in the US delivered by caesarean in 2011. In 2012, close to 23 million C-sections were carried out globally. [ 8 ]


With nearly 1.3 million stays, caesarean section was one of the most common procedures performed in U.S. hospitals in 2011. It was the second-most common procedure performed for people ages 18 to 44 years old. [ 123 ]  Caesarean rates in the U.S. have risen considerably since 1996. [ 124 ]  The rate has increased in the United States, to 33% of all births in 2012, up from 21% in 1996. [ 3 ]  In 2010, the caesarean delivery rate was 32.8% of all births (a slight decrease from 2009's high of 32.9% of all births). [ 125 ]  A study found that in 2011, women covered by private insurance were 11% more likely to have a caesarean section delivery than those covered by Medicaid. [ 126 ]  The increase in use has not resulted in improved outcomes, resulting in the position that C-sections may be done too frequently. [ 3 ]   It is believed that the high rate of induced deliveries has also led to the high rate of c-sections because they are twice as likely to lead to one. [ 127 ]


Hospitals and doctors make more money from C-section births than vaginal deliveries. Economists have calculated that hospitals may make a few thousand dollars more and doctors a few hundred. It has been found that for-profit hospitals do more c-sections than non-profit hospitals. [ 127 ]  One study looked at the rate of c-sections done for women who were themselves doctors.  It found that there was a 10 percent decrease to the rate of c-sections vs the general population.  But if the hospital paid their doctors a flat salary removing the incentive to do the surgical procedures, which take more time, the rate of c-sections done on women who were themselves physicians exceeded that of the procedure done on non-medically knowledgeable mothers, suggesting that some women who actually needed c-sections were not getting them. [ 128 ]


Concerned over the rising number of cesarean deliveries and hospital costs, in 2009  Minnesota  introduced a blended payment rate for either vaginal or cesarean uncomplicated births (i.e., a similar payment regardless of delivery mode).  As a result, the prepolicy cesarean rate of 22.8% dropped 3.24 percentage points. The cost of childbirth hospitalizations in Minnesota dropped by $425.80 at the time the policy was initiated and continued to drop by $95.04 per quarter with no significant effects on maternal morbidity. [ 129 ]


The rise of cesarean births in the United States has coincided with counter-movements emphasizing  natural childbirth  with a lesser degree of medical intervention. [ 104 ] : 101–102


The rate of cesarean sections began to sharply increase in China in the 1990s. [ 104 ] : 101   This increase was driven by the  expansion of China's modern hospital infrastructure , and occurred first in urban areas. [ 104 ] : 101   The rise in cesarean deliveries has also resulted in social critique of the medical establishment over the medical necessity of performing cesarean sections. [ 104 ] : 101–102


Historically, caesarean sections performed upon a live woman usually resulted in the death of the mother. [ 130 ]  It was considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. By way of comparison, see the  resuscitative hysterotomy  or perimortem caesarean section.


According to the ancient Chinese  Records of the Grand Historian , Luzhong ( 陸終 ), a sixth-generation descendant of the mythical  Yellow Emperor , had six sons, all born by "cutting open the body".  The sixth son  Jilian  founded the House of Mi that ruled the  State of Chu  ( c.  1030 –223 BC). [ 131 ]


The  Sanskrit  medical treatise  Sushruta Samhita , composed in the early 1st millennium CE, mentions post-mortem caesarean sections. [ 132 ]  The first available non-mythical record of a C-section is the mother of  Bindusara  (born  c.  320 BC , ruled 298 –  c.  272 BC ), the second  Mauryan   Samrat  ( emperor ) of India, accidentally consumed poison and died when she was close to delivering him.  Chanakya , Chandragupta's teacher and adviser, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life. [ 133 ]


An early account of caesarean section in Iran (Persia) is mentioned in the book of  Shahnameh , written around 1000 AD, and relates to the birth of  Rostam , the legendary hero of that country. [ 134 ] [ 135 ]  According to the  Shahnameh , the  Simurgh  instructed  Zal  upon how to perform a caesarean section, thus saving  Rudaba  and the child Rostam. In Persian literature caesarean section is known as  Rostamina  ( رستمینه ). [ 136 ]


In the  Irish mythological  text the  Ulster Cycle , the character  Furbaide Ferbend  is said to have been born by posthumous caesarean section, after his mother was murdered by his evil aunt  Medb .


The  Babylonian Talmud , an ancient  Jewish  religious text, mentions a procedure similar to the caesarean section. The procedure is termed  yotzei dofen . It also discusses at length the permissibility of performing a C-section on a dying or dead mother. [ 133 ]  There is also some basis for supposing that Jewish women regularly survived the operation in Roman times (as early as the 2nd century AD). [ 137 ]


Pliny the Elder  theorized that Julius Caesar's (born 100 BC) name came from an ancestor who was born by caesarean section, but the truth of this is debated (see the discussion of  the etymology of  Caesar ). Some popular misconceptions involve Caesar himself being born from the procedure; which is considered false because the procedure was lethal to mothers in ancient Rome and Caesar's mother  Aurelia Cotta  lived until he was an adult. [ 138 ] [ 11 ]  The Ancient Roman caesarean section was first performed to remove a baby from the womb of a mother who died during childbirth, a practice sometimes called the  Caesarean law . [ 139 ]


The  Spanish  saint  Raymond Nonnatus  (1204–1240) received his surname—from the  Latin   non-natus  ('not born')—because he was born by caesarean section. His mother died while giving birth to him. [ 140 ]


There is some indirect evidence that the first caesarean section that was survived by both the mother and child was performed in  Prague  in 1337. [ 141 ] [ 142 ]  The mother was  Beatrice of Bourbon , the second wife of the  King of Bohemia John of Luxembourg .  Beatrice  gave birth to the king's son  Wenceslaus I , later the duke of Luxembourg, Brabant, and Limburg, and who became the half brother of the later  King of Bohemia and Holy Roman Emperor, Charles IV .


In an account from the 1580s,  Jakob Nufer , a  veterinarian  in  Siegershausen , Switzerland, is supposed to have performed the operation on his wife after a prolonged labour, with her surviving. His wife allegedly bore five more children, including twins, and the baby delivered by caesarean section purportedly lived to the age of 77. [ 143 ] [ 144 ] [ 145 ]


For most of the time since the 16th century, the procedure had a high mortality rate by modern standards. Key steps in reducing mortality were:


Indigenous people in the  Great Lakes region  of Africa, including  Rwanda  and  Uganda , performed caesarean sections which in one account by  Robert William Felkin  from 1879 resulted in the survival of both mother and child. Banana wine was used, although the site of the incision was then also washed with water and, post operation, covered with a paste made by chewing two different roots. From the well-developed nature of the medical procedures employed he concluded that these procedures had been employed for some time. [ 146 ] [ 147 ] [ 148 ]   James Barry  was the first European doctor to carry out a successful caesarean in Africa, while posted to Cape Town between 1817 and 1828. [ 149 ]


The first successful caesarean section to be performed in the United States took place in Rockingham County, Virginia in 1794. The procedure was performed by Dr.  Jesse Bennett  on his wife Elizabeth. [ 150 ]


The  patron saint  of caesarean section is  Caesarius , a young deacon martyred at  Terracina , who has replaced and Christianized the pagan figure of  Caesar . [ 151 ]  The martyr (Saint Cesareo in Italian) is invoked for the success of this surgical procedure, because it was considered the new "Christian Caesar" – as opposed to the "pagan Caesar" – in the Middle Ages it began to be invoked by pregnant women to wish a physiological birth, for the success of the expulsion of the baby from the uterus and, therefore, for their salvation and that of the unborn. The practice continues, in fact the martyr Caesarius is invoked by the future mothers who, due to health problems or that of the baby, must give birth to their child by caesarean section. [ 152 ]


The origin of the term is not definitively known. Roman  Lex Regia  (royal law), later the  Lex Caesarea  (imperial law), of  Numa Pompilius  (715–673 BC), [ 153 ]  required the child of a mother who had died during childbirth to be cut from her womb. [ 154 ]
There was a cultural  taboo  that mothers should not be buried pregnant, [ 155 ]  that may have reflected a way of saving some fetuses. Roman practice required a living mother to be in her tenth month of pregnancy before resorting to the procedure, reflecting the knowledge that she could not survive the delivery. [ 156 ]


Speculations that the Roman dictator  Julius Caesar  was born by the method now known as C-section are false. [ 157 ]  Although caesarean sections were performed in  Roman  times, no classical source records a mother surviving such a delivery, while Caesar's mother lived for years after his birth. [ 154 ] [ 158 ]  As late as the 12th century, scholar and physician  Maimonides  expresses doubt over the possibility of a woman's surviving this procedure and again becoming pregnant. [ 159 ]  The term has also been explained as deriving from the verb  caedere , 'to cut', with children delivered this way referred to as  caesones .  Pliny the Elder  refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as  ab utero caeso , 'cut from the womb' giving this as an explanation for the  cognomen   Caesar  which was then carried by his descendants. [ 154 ]  Nonetheless,  the  false etymology  has been widely repeated until recently. For example, the first (1888) and second (1989) editions of the  Oxford English Dictionary  say that caesarean birth "was done in the case of Julius Cæsar". [ 160 ]  More recent dictionaries are more diffident: the online edition of the OED (2021) mentions "the traditional belief that Julius Cæsar was delivered this way", [ 161 ]  and  Merriam-Webster's Collegiate Dictionary  (2003) says "from the legendary association of such a delivery with the Roman cognomen  Caesar ". [ 162 ]


The word  Caesar , meaning either Julius Caesar or an emperor in general, is also borrowed or  calqued  in the name of the procedure in many other languages in Europe and beyond. [ 163 ]


Finally, the Roman  praenomen  (given name)  Caeso  was said to be given to children who were born via C-section. While this was probably just  folk etymology  made popular by Pliny the Elder, it was well known by the time the term came into common use. [ 164 ]


The term  caesarean  is spelled in various accepted ways,  as discussed at Wiktionary . The  Medical Subject Headings  (MeSH) of the  United States National Library of Medicine  (NLM) uses  cesarean section , [ 165 ]  while some other American medical works, e.g.  Saunders Comprehensive Veterinary Dictionary , use  caesarean , [ 166 ]  as do most British works. The online versions of the US-published  Merriam-Webster Dictionary [ 167 ]  and  American Heritage Dictionary [ 166 ]  list  cesarean  first and other spellings as "variants".


In re A.C. , 573  A.2d  1235 (1990), was a  District of Columbia Court of Appeals  case. It was the first American appellate court case decided against a forced Caesarean section, although the decision was issued after the fatal procedure was performed. [ 168 ]  Physicians performed a Caesarean section upon patient Angela Carder (née Stoner) without informed consent in an unsuccessful attempt to save the life of her baby. [ 169 ]   The case stands as a landmark in United States  case law  establishing the  rights  of informed consent and bodily integrity for pregnant women.


In Illinois,  In re Baby Boy Doe , 632 N.E.2d 326 (Ill. App. Ct. 1994) was a court case holding that courts may not balance whatever rights a fetus may have against the rights of a competent woman, whose choice to refuse medical treatment as invasive as a Cesarean section must be honored even if the choice may be harmful to the fetus.


Pemberton v. Tallahassee Memorial Regional Center , 66 F. Supp. 2d 1247 (N.D. Fla. 1999), is a case in the  United States  regarding  reproductive rights . Pemberton had a previous Caesarean section (vertical incision), and with her second child attempted to have a  VBAC  (vaginal birth after c-section). [ 170 ]  When a doctor she had approached about a related issue at the  Tallahassee Memorial Regional Center  found out, he and the hospital sued to force her to get a c-section. The court held that the rights of the fetus at or near birth outweighed the rights of Pemberton to determine her own medical care. [ 171 ] [ 172 ]  She was physically forced to stop laboring, and taken to the hospital, where a c-section was performed. [ 170 ]  Her suit against the hospital was dismissed. [ 170 ]   The court held that a cesarean section at the end of a full-term pregnancy was here deemed to be medically necessary by doctors to avoid a substantial risk that the fetus would die during delivery due to uterine rupture, a risk of 4–6% according to the hospital's doctors and 2% according to Pemberton's doctors. Furthermore, the court held that a state's interest in preserving the life of an unborn child outweighed the mother's constitutional interest of bodily integrity. [ 173 ]  The court held that  Roe v. Wade  was not applicable, because bearing an unwanted child is a greater intrusion on the mother's constitutional interests than undergoing a cesarean section to deliver a child that the mother affirmatively desires to deliver. The court further distinguished  In re A.C.  by stating that it left open the possibility that a non-consenting patient's interest would yield to a more compelling countervailing interest in an "extremely rare and truly exceptional case." The court then held this case to be such. [ 170 ] [ 174 ]


In many hospitals, the mother's partner is encouraged to attend the surgery to support her and share the experience. [ 175 ]  While traditionally there has been an opaque surgical drape obstructing the parents' view, some patients and doctors are opting for a "gentle C-section" using a clear drape, allowing the parents to watch the delivery and see their infant immediately. [ 176 ]


In  Judaism , there is a dispute among the  poskim  (Rabbinic authorities) as to whether the first-born son from a caesarean section has the laws of a  bechor . [ 177 ]  Traditionally, a male child delivered by caesarean is not eligible for the  Pidyon HaBen  dedication ritual. [ 178 ] [ 179 ]


In rare cases, caesarean sections can be used to remove a dead  fetus ; otherwise, the woman has to labour and deliver a baby known to be a  stillbirth . A  late-term abortion  using caesarean section procedures is termed a  hysterotomy abortion  and is very rarely performed. [ 180 ]


The mother may perform  a caesarean section on herself ; there have been successful cases, such as Inés Ramírez Pérez of Mexico who, on 5 March 2000, took this action. She survived, as did her son, Orlando Ruiz Ramírez. [ 181 ] [ 182 ] [ 183 ]


In 2024, a female  western lowland gorilla  had a successful cesarean section after zoo veterinarians diagnosed her with  pre-eclampsia . The premature gorilla infant survived, as a result of similar methods used with human infants. [ 184 ]


A  caudle  (or  caudel ) [ 1 ]  was a hot drink that recurred in various guises throughout  British cuisine  from the Middle Ages into Victorian times. It was thick and sweet, and seen as particularly suitable and sustaining for invalids and new mothers. At some periods of history, caudle recipes were based on milk and eggs, like  eggnog . Later variants were more similar to a  gruel , a sort of drinkable oatmeal porridge. Like the original forms of  posset  (a drink of wine and milk, rather than a set dessert), a caudle was usually alcoholic.


There were special  caudle cups , larger than teacups, often with a cover, and perhaps two handles. These were either in pottery or metal, and might be given as presents.


The word  caudle  came into  Middle English  via the  Old North French  word  caudel , ultimately derived from  Latin   caldus , "warm". [ 2 ]  According to the  Encyclopædia Britannica  Eleventh Edition , the word derived from Medieval Latin  caldellum , a diminutive of  caldum , a warm drink, from  calidus , hot. [ 3 ]  The  Oxford English Dictionary  cites the use of the word to 1297. The word's etymological connection to heat makes it  cognate  with "cauldron".


A related recipe for  skyr , a cultured dairy product, appears in the early 13th century. [ 4 ]  The earliest surviving recipe for caudle, from 1300 to 1325, is simply a list of ingredients: wine, wheat starch, raisins, and sugar to "abate the strength of the wine". [ 5 ]


Another recipe from the late 14th century has more ingredients and more details on the cooking procedure: mix breadcrumbs, wine, sugar or honey, and saffron, bring to a boil, then thicken with egg yolks, and sprinkle with salt, sugar, and ginger. [ 6 ] [ 7 ]  A 15th-century English cookbook includes three caudle recipes: ale or wine is heated and thickened with egg yolks and/or ground almonds, then optionally spiced with sugar, honey, saffron, and/or ginger (one recipe specifically says "no salt"). [ 8 ]  In a description of an  initiation ceremony  at  Merton College, Oxford  in 1647, caudle is described as a "syrupy gruel with spices and wine or ale added". [ 9 ]   William Carew Hazlitt  provides a number of recipes for caudles and  possets  in his 1886 book,  Old Cookery Books and Ancient Cuisine . [ 10 ]


The  Encyclopædia Britannica  Eleventh Edition  describes it as "a drink of warm  gruel , mixed with spice and wine, formerly given to women in childbed", [ 3 ]  i.e. as a restorative food during her  postpartum confinement .


Emily Post 's 1922  Etiquette in Society, in Business, in Politics, and at Home , the classic guide to American manners, states that "although according to cook-books caudle is a gruel, the actual "caudle" invariably served at christenings is a hot  eggnog , drunk out of little punch cups" [ 11 ]  (see  Punch bowl ).


Aside from the initiation ceremony mentioned above, caudle was often served to people who were seen to need strengthening, especially invalids and new mothers. A historian of  Georgian England  says that  maternity hospitals  always served a "traditional postlabor fortified caudle" to women who had just given birth. [ 12 ]  The  British Lying-In Hospital  had "Laws, Orders, and Regulations" printed to be displayed on the wards, detailing among other things, the menu. Mothers on the "low diet" had caudle; when they graduated to the "common diet" it was beer caudle; and the "full diet" had no need of the invalid liquid anymore. [ 13 ]


Maria Rundell  included a "caudle for the sick and lying-in" in her best-selling  A New System of Domestic Cookery  (1806). [ 14 ]  (" Lying-in " is an obsolete term for childbirth, referring to the extended period of  bed rest  that marked the traditional recuperation time.)  Judith Montefiore  likewise included caudle with the "recipes for invalids" in her  The Jewish Manual  (1846), the first exposition of  Jewish cuisine  in English. [ 15 ]  Five years later,  The English Housekeeper  by  Anne Cobbett  (daughter of  William Cobbett ) gives variants of caudles, of either gruel (oatmeal) or rice, with different types of alcohol, and seasonings, including  capillaire . She devotes a chapter to invalid food, making the point that "Often when the Doctor's skill has saved the life of his patient [...] it remains for the diligent nurse to prepare the cooling drinks and restorative foods [...]. Everything which is prepared for a sick person should be delicately clean, served quickly, in the nicest order; and in a small quantity at a time." [ 16 ]


As caudel was served to new mothers to build up their strength, so it was offered to their visitors, to share in the happy occasion. "Cake and caudel" or "taking caudle" became  the accepted phrases  for a "lying-in visit", when women went to see their friends' new babies. These were  all-female occasions , as more than one man noted. The American playwright  Royall Tyler  has one of the female characters in the  comedy of manners   The Contrast  (1787) decline the offer of a man's escorting her by claiming that "half [her] visits are cake and caudel" and therefore unsuitable for him. [ 17 ]  A generation later in 1821,  Thomas Gaspey  wrote of these visits (with the italics in the original):


'Twas then Eliza, though now Mrs. T.
We ought to call her, gave her lord an heir,
And all her female friends, the babe to see
And praise its beauty, failed not to repair;
But half what they to utter there thought meet,
While  taking caudle , I must not repeat.


Offering caudel, or cake and caudel, to all lying-in visitors is referred to as an old British custom.  Queen Charlotte , consort of  George III , bore him 15 princes and princesses.  After the christening of the youngest,  Princess Amelia  in 1783, "the greater part of the company then paid a visit to the nursery, where they were entertained (as usual on such occasions) with cake and caudel." [ 18 ]  This continued into  Queen Victoria 's reign: the day after she gave birth to the  Prince of Wales , "many of the female Nobility called at Buckingham Palace, and were received by  Lady Charlemont , the  Lady in waiting , and after taking caudle were taken to the north wing to see the infant Prince." [ 19 ]


But it was not just nobles who came.  The Court Magazine and Belle Assemblée  reported that the aftermath of a royal birth was "a usual reception of the public to cake and caudel". [ 20 ]  The  London Chronicle  reported in 1765 that "The resort of different ranks of people at St. James's to receive the Queen's Caudle is now very great." [ 21 ]


After the birth of  Princess Augusta Sophia , the sixth child of George III and Queen Charlotte:


Connected with the event of her Royal Highness's birth,  during the usual reception of the public to cake and caudle, on Sunday 13th of November, 1768, a curious incident occurred at the Palace: - two young ladies, after having drunk plentifully of caudle, were detected in carrying off a large portion of the cake, and some of the cups in which the caudle had been served; they were allowed, however, to escape with a severe reprimand, after begging pardon on their knees for so disgraceful an act. [ 22 ]


In England, the custom had died out by around 1850, [ 23 ]  but the birth of the current King  Willem-Alexander of the Netherlands  in  Utrecht  in 1967 was celebrated there a few days later by an apparently all-male caudle ( candeel  in Dutch) party including  his father , the  Prime Minister , and other dignitaries, who wore  morning dress  to eat caudle with teaspoons from highly decorated handleless cups with saucers, held up near the mouth, as the photos in the state archives show. [ 24 ]   The event was held in the Utrecht city hall, where after the caudle the new prince's birth was registered by the mayor.  The birth of the prince's mother, Queen  Beatrix of the Netherlands , in 1938 had also been celebrated with a caudle party.


There was a vessel particular to the drink, the caudle cup, a traditional gift, either  for a pregnant woman , [ 25 ]  or on visits by female friends to the mother lying-in. [ 26 ]   Late 17th and early 18th-century examples in silver are low bulbous bowls with two handles, and often a cover. These were passed around among the company. [ 27 ]


Poorer people used small bulbous and handleless earthenware cups, often painted with the monarch.  In the early 18th century lidded "spout pots" were used; these were two-handled with a teapot-style spout on one of the other sides. [ 28 ]  As European  porcelain  developed in the 18th century, the two-handled cup with a cover, similar to the shape called a "chocolate cup" in continental examples, but often more bulbous, became the usual form of caudle cup, now with a saucer.  These were typically highly decorated with  overglaze enamel  painting, and presented by the wealthy in pairs to new mothers.  They were now smaller, and probably for individual use.  Other than their use when lying-in, they functioned as  cabinet cups , too ornate and expensive for regular use, and displayed in a  china cabinet . In a London auction of  Chelsea porcelain  and  Derby porcelain  in 1771 the most expensive examples were sold for £12 for a pair, a considerable sum. They continued to be made through the 19th century as cabinet pieces, after the custom of consuming caudle largely died away. [ 29 ]


At lower levels of society, an alternative pottery gift to bring to a lying-in caudle party was a model  cradle  complete with baby, into which coins or a small gift were added. These were rarely of fine porcelain. [ 30 ]


A caudle formed part of the  Beltane  (May Day)  fire festival  celebrations collated by  James Frazier  in  The Golden Bough . He quotes at length  Thomas Pennant , "who traveled in Perthshire in the year 1769":


on the first of May, the herdsmen of every village hold their Bel-tien, a rural sacrifice. They cut a square trench on the ground, leaving the turf in the middle; on that they make a fire of wood, on which they dress a large caudle of eggs, butter, oatmeal and milk; and bring besides the ingredients of the caudle, plenty of beer and whisky; for each of the company must contribute something. The rites begin with spilling some of the caudle on the ground, by way of libation: on that everyone takes a cake of oatmeal, upon which are raised nine square knobs, each dedicated to some particular being, the supposed preserver of their flocks and herds, or to some particular animal, the real destroyer of them: each person then turns his face to the fire, breaks off a knob, and flinging it over his shoulders, says, 'This I give to thee, preserve thou my horses; this to thee, preserve thou my sheep; and so on.' After that, they use the same ceremony to the noxious animals: 'This I give to thee, O fox! spare thou my lambs; this to thee, O hooded crow! this to thee, O eagle!' When the ceremony is over, they dine on the caudle; and after the feast is finished, what is left is hid by two persons deputed for that purpose; but on the next Sunday they reassemble, and finish the reliques of the first entertainment.


Frazier notes other Scottish May Day celebrations with similar dishes, "a repast of eggs and milk in the consistence of a custard". [ 31 ]


Apparently it was "a custom in France to bring the bridegroom a caudle in the middle of the night on his wedding-night", according to an explanatory note in an 1877 edition of  The Essays of Montaigne , presumably inserted by the English editor,  William Carew Hazlitt . [ 32 ]


A  chignon  (an artificially induced  caput succedaneum ) is a temporary swelling caused by a build-up of bloody fluid left on an  infant 's head after they have been  delivered  by  vacuum extraction . A vacuum extraction is a type of assistance used during vaginal delivery by an obstetrician or midwife when the second stage of labor, where the  cervix  is fully dilated allowing for fetus delivery, is stalled. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]   It anatomically resembles regular caput succedaneum, one of two most frequently occurring birth injuries to the head, the other being  cephalohematoma , a usually harmless condition where blood accumulates under the newborn's scalp after vaginal delivery. [ 6 ] [ 7 ]


During  vacuum extraction , the cup is attached to the infant's head, exposing the infant to trauma due to the vacuum pressure and pulling force involved in the procedure. [ 6 ]  This form of assisted delivery is typically required when the labor is stalled due to difficulties in the stages of labor arising, such as when the infant's head found too high in the  birth canal . Due to prolonged pressure and tension, this induces an accumulation of  interstitial fluid  (the fluid that surrounds cells) as well as possible minor  hemorrhages , ultimately resulting in scalp swelling. [ 8 ] [ 9 ]


A chignon should not be mistaken for bruises or other similar fetal head traumas relating to vacuum extraction. [ 10 ]  It chignon should begin to resolve within an hour, but it may take between 12 and 18 hours to completely disappear. [ 11 ] [ 12 ]  There are no long-term consequences for the newborn, but as with all birth traumas, it is recommended to be attended to and monitored. [ 6 ] [ 11 ]


When the vacuum is applied to the infant's head, the tension creates a difference in pressure between the atmosphere and the infant's scalp that causes the soft tissue layers of the scalp to fill inside the suction cup. [ 5 ] [ 6 ]  Subsequently, interstitial fluid and small hemorrhages build up, causing the head to swell and forming a localized edema. [ 11 ] [ 5 ] [ 9 ]  A chignon must be formed when performing a vacuum extraction with a hard plastic or metal cup in order to effectively adhere to the infant's head. [ 13 ]  This occurs because a hard cup does not spread out over the head like a soft cup. [ 12 ]  Because it takes a maximum of 2 minutes for a chignon to form, the vacuum extraction should be completed within 15 minutes in order to prevent injury to the baby. [ 13 ]  A soft cup does not require a chignon to form and is associated with less trauma to the infant, despite a higher risk of cup detachment, which can lead to other injuries, such as lacerations to the scalp. [ 13 ]


A chignon is firm and can cross suture lines, and it is often circular in appearance due to the shape of the suction cap. [ 11 ] [ 14 ] [ 15 ]  The swelling may shift to each side depending on the position of the infant's head. [ 6 ]


While a chignon and caput succedaneum are anatomically the same, a chignon is induced by the suction cup used during a vacuum extraction, while a true caput succedaneum is a natural buildup of fluid caused by the pressure induced when the infant's head passes through its mother's cervix. [ 5 ] [ 16 ]  A chignon always involves a buildup of serosanguinous fluid, but a caput succedaneum can involve either serosanguineous or hemorrhagic fluid. [ 5 ] [ 16 ]  Serosanguinous fluid is defined as fluid collected or leaving the body, containing both blood as well as the liquid portion of the blood ( serum ). [ 17 ]


Clinically, a caput succedaneum is soft and uneven, with a depth of about 1 to 2 cm. It can include petechiae, (small, pinpoint red or purple spots due to bleeding), purpura (a purple rash due to blood vessel leakage), and/or a bruised appearance. [ 6 ] [ 18 ] [ 19 ]  Like a chignon, a caput succadaneum is usually benign and should resolve within a few days postpartum. [ 6 ]


Unlike a chignon, a caput succedaneum can lead to further complications, such as  halo scalp ring , a form of hair loss or alopecia. [ 6 ]  In some cases, a caput succadaneum can cause permanent hair loss or scarring. [ 6 ]  Finally, jaundice is also a known possible complication of caput succedaneum. [ 16 ]


Unlike a chignon with no long-term consequences, a subgaleal hemorrhage is a more severe instance of trauma associated with vacuum extraction and forceps delivery, however most commonly caused by vacuum extraction.  A subgaleal hemorrhage is introduced into the loose connective tissue found within the subgaleal space, ultimately causing  hypovolaemia . Hypovolemia is defined as a state of having a depleted circulating blood volume or fluids in the body. [ 20 ]  This issue arises when the infant loses about 50-70% of the circulating blood volume, leading to complications such as  hypovolemic shock ,  anemia , and  coagulopathy . [ 21 ]  While subgaleal hemorrhage is a rare complication, it is considered lethal. [ 9 ]


Clinical manifestations of a subgaleal hemorrhage are variable; it is recommended that the mean time for diagnosis is typically within 1–6 hours after birth, especially if the infant delivery was through vacuum delivery or prolonged due to complications. [ 22 ] Therefore, close monitoring of a newborn infant is prompted with a minimum of eight hour observation for all infants delivered by vacuum extractions or forceps deliveries. [ 11 ] A subgaleal hemorrhage may initially look like a caput succedaneum or a chignon because blood crosses the suture lines for all three conditions. [ 6 ]  However, notifiable signs of a subgaleal hemorrhage include fluctuant scalp swelling, a  lesion  crossing the suture lines,  pitting edema  continuing over the head, and  fluid wave test . [ 21 ]


If a subgaleal hemorrhage is suspected, measures such as hemoglobin count should be performed immediately and monitored every 4-8 hours. Also, imaging for subgaleal hemorrhage such as  CT ,  MRI  or  radiographs  of the skull can be done in order to identify any notifiable fractures. [ 21 ] [ 9 ]  Through early recognition and careful monitoring,  hypovolemic shock  can be avoided. When any form of assisted delivery devices have been used during labor, the individual(s) caring for the child must be notified that the child must be regularly examined and monitored. By doing so, increasing awareness of chignons and subgaleal hemorrhages will lead to earlier identification, referral and treatment. [ 14 ] [ 11 ] [ 9 ]


Chignon and  cephalohematoma  are both relatively common birth injuries which occur to the newborn's head during vacuum delivery.  Cephalohematoma  and chignon are considered to pose no long-term consequences on a newborn's health. [ 6 ]


A  cephalohematoma  which occurs in 0.4% to 2.5% of live births, is where pressure during vaginal delivery to the fetal head causes blood vessels rupture in the  periosteum  (a membrane layer covering bone exterior) leading to blood accumulation in the subperiosteal space, a space situated below the  periosteum . [ 23 ] [ 24 ]  While the chignon may cross suture lines, cranial sutures (strong tissue that is naturally found connecting the bones of the skull together) are the boundaries for  cephalohematoma . [ 6 ] [ 22 ] [ 25 ]  As the accumulation of blood into the subperiosteal space is relatively slow, unlike the chignon which immediately occurs upon use of vacuum extraction, cephalohematomas will arise during the first one to three days after birth. [ 23 ]


Cephalohematomas more frequently will occur during delivery of infants assigned male at birth compared to infants assigned female at birth, however the reasons are unknown. Some other common factors that can cause cephalohematoma are when using forceps or vacuum-assisted delivery methods, vaginal delivery of large infants, primigravida (the first pregnancy conceived by a pregnant person), when the infant is in a non-ideal position during delivery, and having a prolonged second stage of labor. [ 23 ]


Similar to chignon, treatment for  cephalohematoma  is not required as the body is expected to reabsorb the fluid accumulating in the subperiosteal space. Attempting to drain or aspirate the collected fluid may result in an infection and abscess formation, and is therefore not recommended. [ 23 ]


Chignons are essentially both normal and harmless byproducts of vacuum-assisted delivery. In practically all cases, chignons disappear on their own within a couple of days postpartum and do not necessitate medical treatment. [ 6 ]  However, as noted, chignons are not the only side effects induced by vacuum-assisted delivery; therefore, it is still necessary to keep an eye out during the healing process in the event of other possible complications. [ 6 ] [ 26 ]  Prolonged vacuum traction, improper cup placement, and sudden cup detachment are all factors contributing to both maternal and neonatal complications that need to be considered when applying vacuum extraction. [ 26 ]


Despite the known risks of vacuum-assisted delivery, it nowadays tends to be a more commonly used birth-assisting tool due to its relatively lower occurrences of both maternal and neonatal complications compared to other methods, such as using forceps or a  C-section , which tends to be a last resort option due to risks of significantly greater maternal morbidity. [ 3 ] [ 27 ]  There have also been developed practices to minimize the impact of vacuum-assisted delivery on the neonatal head. Such a method is to use a proper vacuum cup to apply pressure up to 0.8 kg/cm 2  and rhythmically sync the vacuum with uterine contractions in order to both expedite the delivery process and minimize traction-induced scalpel swelling. [ 26 ]  The infant's head should be regularly checked throughout the hospital stay. [ 10 ]


It is crucial to know when to stop; the longer the delay, the higher the chance of both maternal and neonatal complications developing. [ 28 ]  All in all, both communicating with and updating healthcare personnel are key; parents and caretakers are encouraged to immediately report any changes or signs of worsening complications. [ 6 ]


Childbirth positions  (or  maternal birthing positions ) [ 1 ]  are the physical  postures  that the pregnant mother may assume during the process of  childbirth . They may also be referred to as  delivery positions  or  labor positions .


In addition to the  lithotomy position  (on back with feet pulled up), still commonly used by many  obstetricians , other positions are successfully used by  midwives  and traditional birth-attendants around the world.  Engelmann's  seminal 1882 work "Labor among primitive peoples" publicised the childbirth positions amongst primitive cultures to the Western world. They frequently use  squatting ,  standing ,  kneeling  and  all fours  positions, often in a sequence. [ 2 ]  They are referred to as  upright birth positions . [ 3 ]


Understanding the physical effects of each birthing position on the mother and baby is important. However, the psychological effects are crucial as well. Knowledge about birthing positions can help mothers choose the option they are most comfortable with. Having the agency and self-control to change positions in labor positively influences the mother's comfort and birthing experience, which increases the birthing outcome and her satisfaction with labor.  [ 4 ]


In the lithotomy position, the birthing person is lying on their back with their legs up in stirrups and their buttocks close to the edge of the table. [ 5 ]  This position is convenient for the caregiver because it permits them more access to the  perineum .


The position has been largely popular in the US and other Western countries over the last two centuries, though cross-culturally and historically, it is very rare (about 18%) for people to assume a prone or dorsal position during childbirth. Reclining positions became common in France during the 17th century, as obstetrics became a more respected field and ideas of birth being an affliction rather than natural became widespread. The standard of women lying flat on their back originated in the early 19th century in the US, and was recommended by male obstetricians on the basis of claims that the position was both more convenient for attending medical staff and that women would be more comfortable lying on their backs. [ 6 ]


However, the lithotomy is not a comfortable position for most patients, considering the pressure on the vaginal walls because the baby's head is uneven and the labor process is working against gravity. [ 7 ]  Research suggests that maternal bodily positions have a notable influence on pain experienced during labor and delivery, and that positions such as squatting show significantly reduced pain compared to the lithotomy position. [ 8 ]


Various people have promoted the adoption of upright birthing positions, particularly squatting, for Western countries, such as  Grantly Dick-Read ,  Janet Balaskas ,  Moysés Paciornik  and  Hugo Sabatino . The adoption of the non-lithotomy positions is also promoted by the  natural childbirth  movement.


Being upright during labour and birth can increase the available space within the pelvis by 28–30% giving more room to the baby for rotation and descent. There is also a 54% decreased incidence of foetal heart rate abnormalities when the mother is upright. [ 9 ]  These birthing positions can also reduce the duration of the second stage of labour [ 10 ]  as well as reduce the risk for emergency  caesarian sections  by 29%. [ 11 ]  They are also associated with the lower need for  epidural . [ 11 ]


Different positions may be associated with different rates of  perineal injury . [ 12 ] [ 13 ]


The squatting position gives a greater increase of pressure in the pelvic cavity with minimal muscular effort. The birth canal will open 20 to 30% more in a squat than in any other position. It is recommended for the  second stage of childbirth . [ 14 ]


As most Western adults find it difficult to squat with heels down, compromises are often made such as putting a support under the elevated heels or another person supporting the squatter. [ 15 ]


In  ancient Egypt , women delivered babies while squatting on a pair of  bricks , known as  birth bricks . [ 16 ]


Some mothers may choose the all-fours position instinctively. It can help the baby turn around in the case of a malpresentation of the head. Since this position uses gravity, it decreases back pain, [ 7 ]  as the mother is able to tilt her hips. [ 17 ]


Side lying may help slow the baby's descent down the birth canal, thereby giving the perineum more time to naturally stretch. To assume this position, the mother lies on her side with her knees bent. To push, a slight rolling movement is used such that the mother is propped up on one elbow is needed, while one leg is held up. This position does not use gravity but still holds an advantage over the lithotomy position, as it does not position the  venae cavae  under the  uterus , which decreases blood flow to mother and child. [ 7 ]


In Christian tradition the  churching of women , also known as  thanksgiving for the birth or adoption of a child , is the ceremony wherein a blessing is given to mothers after recovery from  childbirth . The ceremony includes thanksgiving for the woman's survival of childbirth, and is performed even when the child is stillborn, or has died unbaptized.


Although the ceremony itself contains no elements of  ritual purification , it was related to Jewish practice as noted in  Leviticus 12:2–8 , where women were  purified after giving birth . In light of the  New Testament , the Christian ritual draws on the imagery and symbolism of the  presentation of Jesus at the Temple
( Luke 2:22–40 ). Although some Christian traditions consider Mary to have borne Christ without incurring impurity, she went to the  Temple in Jerusalem  to fulfil the requirements of the  Law of Moses .


The rite is first mentioned in pseudo-Nicene Arabic  canon law . [ 1 ]  The Christian rite for the churching of women continues in  Eastern Christianity , the  Lutheran Churches , the  Anglican Communion  and the  Methodist Churches ; [ 2 ]  but in the  Roman Rite  it is found only in the  pre-Vatican II form  and in  Anglican Ordinariate  parishes.


The custom of blessing a woman after childbirth recalls the Purification of the Blessed Virgin Mary mentioned in Luke 2:22. The Jewish practice was based on Leviticus 12:1-8, which specified the ceremonial rite to be performed in order to restore ritual purity. It was believed that a woman becomes ritually unclean by giving birth owing to the presence of blood and/or other fluids at birth. This was part of ceremonial rather than moral law. [ 3 ]


Natalie Knödel noted that the idea that a woman who has recently given birth is to be set apart and then reintroduced into religious and social life by means of a special rite is not a specifically Western, let alone Christian, idea. Such rites are found in a number of cultures. All things having to do with birth and death are understood as somehow sacred. [ 4 ]  Paul V. Marshall suggests that in an agricultural society this could have been a simple means of protecting a new mother from resuming work too soon after giving birth. [ 5 ]  Enforced rest after childbirth is known as  postpartum confinement . Historically, European women were confined to their beds or their homes for extensive periods  after giving birth  in a custom called  lying-in ; care was provided either by her female relatives (mother or mother-in-law) or by a temporary attendant known as a  monthly nurse . "Churching" served to mark the end of these weeks of separation and reintegrate the new mother into her community. [ 6 ]


The rite became the subject of a good deal of misunderstanding, since many commentators and preachers, in describing its scriptural antecedents, did not explain the concept clearly.  Pope Gregory I  as early as the 6th century protested against any notion that defilement was incurred by childbirth and recommended that women should never be separated from the church in case it was seen as such. [ 7 ]  As a blessing given to mothers after recovery from childbirth, "it is not a precept, but a pious and praiseworthy custom, dating from the early Christian ages." [ 8 ]   David Cressy  points out that the ceremony acknowledged the woman's labours and the perils of childbirth. At the conclusion of a month after childbirth, women looked forward to churching as a social occasion, and a time to celebrate with friends. For men it marked the end of a month during which they had to take care of the domestic affairs, commonly referred to as the "gander month". [ 9 ]  In thirteenth-century France the rite focused on the woman's role as wife and mother. [ 10 ]


The Second Plenary Council of Baltimore, an American Roman-Catholic gathering held in October 1866, noted that churching after childbirth had been generally neglected in the United States and was to be insisted upon, [ 11 ]  and prohibited the practice of churching in places in which Mass is not celebrated. [ 8 ]


The custom, referred to in many places as the "Churching of Women", was retained in the Church until very recent times, and still is in the old rite. [ 12 ]  The official title of the Rite was actually  Benedictio mulieris post partum  (the blessing of a woman after giving birth), and focused on blessing and thanksgiving. The rite largely fell into disuse in the late 1960s following the  Second Vatican Council , but a number of  traditional Catholic  women still undergo the rite. The Book of Blessings published in 1984 contains a "Blessing of a Woman after Childbirth" that is significantly altered from the old rite used before the Council, but fulfills the same liturgical purpose. The current baptismal rite (which also incorporates a blessing of the father) contains a blessing for the mother, but the older rite is a special blessing. [ 3 ]


The concluding prayer reads:


Almighty, everlasting God, through the delivery of the blessed  Virgin Mary , Thou hast turned into joy the pains of the faithful in childbirth; look mercifully upon this Thy handmaid, coming in gladness to Thy temple to offer up her thanks: and grant that after this life, by the merits and intercession of the same blessed Mary, she may merit to arrive, together with her offspring, at the joys of everlasting happiness. Through Christ our Lord. [ 3 ]


The "Order for the Blessing of a Mother after Childbirth" is still used, primarily for those mothers who were unable to attend the baptism, and is not necessarily held in a church. It may be imparted by a priest, deacon or authorized lay minister. [ 13 ]


The churching of women was historically offered to women in the  Lutheran Church , [ 14 ] [ 15 ]  taking place after the celebration of  Holy Communion [ 16 ]  in the liturgy.


A prayer "For the Churching of Women" as it appeared in the 1918 liturgy of  The Lutheran Church—Missouri Synod , reads as follows: [ 17 ]


God, we praise Thee for Thy great mercy shown to this mother and her child, and humbly beseech Thee to keep them always in Thy gracious care. Hear, O Lord, the supplications of the mother, take her into Thy fatherly protection, and compass her with Thy favor as with a shield. Dispose and enable the parents to give their child a Christian training, that so it may grow up to Thine honor and the joy of all true believers. Amen. [ 17 ]


The rite of the "Churching of Women" is offered in the Anglican Communion with a liturgy as part of the  Book of Common Prayer . [ 18 ] [ 19 ]


In the US-based  Episcopal Church , the "Churching of Women" is a liturgy for the purification or "churching" of women after childbirth, together with the presentation in church of the child. The 1979  Book of Common Prayer , avoiding any hint of ritual impurity, replaces the older rite with "A Thanksgiving for the Birth or Adoption of a Child." The rite is to take place within the Sunday liturgy, after the intercessions, soon after the birth or adoption. In this service, parents and other family members come to the church with the newly born or adopted child "to be welcomed by the congregation and to give thanks to Almighty God" (Book of Common Prayer, p. 439). [ 20 ]


The rite of the churching of women, officially known as the "An Order of Thanksgiving for the Birth or Adoption of a Child", continues to be offered in Methodist churches. [ 2 ]  The rubrics concerning the rite state:


Following the birth or adoption of a child, the parent(s), together with other members of the family, may present the child in a service of worship to be welcomed by the congregation and to give thanks to God. Part or all of this order may be included in any service of congregational worship. Thanksgiving for the birth or adoption of a child may also be offered to God in a hospital or home, using such parts of this order as are appropriate. It should be made clear to participants that this act is neither an equivalent of nor a substitute for Holy Baptism but has an entirely different history and meaning. This act is appropriate (1) prior to the presentation of the child for baptism, or (2) if the child has been baptized elsewhere and is being presented for the first time in the congregation where his or her nurture is to take place. [ 2 ]


Custom differs, but the usual date of churching was the fortieth day after confinement (or giving birth), in accordance with the Biblical date and Jewish practice. [ 1 ]  The Purification of Mary and the presentation of Jesus at the Temple are commemorated forty days after Christmas.


The service included in the English  Book of Common Prayer  dates only from the  Middle Ages . [ 1 ]  While the churching was normally performed by a priest in the parish church there were exceptions of women being churched at home. [ 4 ]


Prior to the  English Reformation , according to the rubric the woman was to occupy the "convenient place" near the  narthex . In the first prayer book of  Edward VI of England , she was to be "nigh unto the quire door". In the second of his books, she was to be "nigh unto the place where the Table (or altar) standeth". Bishop  Matthew Wren  orders for the  diocese of Norwich  in 1636 were that women to be churched would come and kneel at a side near the  communion table  outside the rail, being veiled according to custom, and not covered with a  hat . In some parishes there was a special pew known as the "churching seat". [ 1 ]  Conducting the ritual inside the church rather than on the porch is an outward sign that ritual impurity of a childbearing woman was no longer presumed. [ 4 ]


Churchings were formerly registered in some parishes. In  Herefordshire  it was not considered proper for the husband to appear in church at the service, or to sit with his wife in the same  pew . The words in the  rubric  requiring the woman to come "decently apparelled", refer to the times when it was thought unbecoming for a woman to come to the service with the elaborate head-dress then the fashion. A  veil  was usually worn. In some parishes a special veil was provided by the church, for an inventory of goods belonging to  St Benet Gracechurch  in 1560 includes "a churching cloth, fringed, white damask." [ 1 ]


In pre-Reformation days, it was the custom in Catholic England for women to carry lighted  tapers  when being churched, an allusion to the Feast of the Purification of the Virgin (February 2), and also celebrated as  Candlemas , the day chosen by the  Catholic Church  for the blessing of the candles for the whole year. At her churching, a woman was expected to make some  votive offering  to the church, such as the  chrisom  or  alb  placed on the child at its  christening . [ 21 ]


Augustine Schulte described the ceremony in the early twentieth century: The mother, kneels in the vestibule, or within the church, carrying a lighted candle. The priest, vested in surplice and white stole, sprinkles her with holy water in the form of a cross. Having recited Psalm 24, "The earth is the Lord's and the fullness thereof", he offers her the left extremity of the stole and leads her into the church, saying: "Enter thou into the temple of God, adore the Son of the Blessed Virgin Mary who has given thee fruitfulness of offspring." She advances to one of the altars and kneels before it, whilst the priest, turned towards her, recites the appropriate blessing, and then, having sprinkled her again with holy water in the form of the cross, dismisses her, saying: "The peace and blessing of God Almighty, the Father, the Son, and the Holy Ghost, descend upon thee, and remain forever. Amen." [ 8 ]  According to  commentary provided in a modern Catholic tutorial on the mass, the fact that the priest goes to meet the mother and escort her into the church is in itself a mark of respect for her. [ 22 ]


It was formerly regarded as unwise for a woman to leave her house to go out at all after confinement until she went to be churched. [ 1 ]  In Anglo-Irish folk tradition, new mothers who had yet to be churched were regarded as attractive to the  fairies , and so in danger of being kidnapped by them. However, the origin of the church ritual is unrelated to these later local superstitions, which accrued to it.


In the  Eastern Orthodox  and  Eastern Catholic Churches  of the  Byzantine Rite , many jurisdictions still observe the tradition of the woman coming to church on the 40th day after childbirth for special blessings. For forty days a new mother remains at home to recuperate and to care for her child. However, if the child has not survived, the woman still remains at home to heal physically and emotionally. During the time of her confinement, the woman does not normally receive the  eucharist , unless she is in danger of death. As the service is practiced in the Byzantine Rite, it involves both the blessing of the mother and the presentation of the child to God. The churching should be distinguished from two other brief rites that take place at childbirth: the  Prayers on the First Day After Childbirth , and the  Naming of the Child on the Eighth Day . These usually take place in the home. In some traditions, it is customary to  baptize  the child on the eighth day, following the example of the  Old Testament  rite of  bris  or  circumcision  of boys. In that case, the naming of the child would take place in the  temple  (church building); however, the mother would not attend, the child being presented by its  godparents .


On the fortieth day after childbirth, the mother is brought to the temple to be churched; that is to say, to receive a blessing as she begins attending church and receiving the sacraments once again. The child (if it has survived) is brought by the mother, who has already been cleansed and washed, accompanied by the intended  sponsors  (Godparents) who will stand at the child's baptism. They all stand together in the narthex before the doors of the  nave , facing east. The  priest  blesses them and says prayers for the woman and the child, giving thanks for their wellbeing and asking God's grace and blessings upon them.


Then, if the infant has already been baptized, he performs the churching of the child; if not, he does the churching immediately after the baptism.


Taking up the child, the priest lifts it up, making the  sign of the cross  with the child before the doors of the temple, saying: "The servant of God  (Name)  is churched, in the Name of the Father, and of the Son, and of the Holy Spirit. Amen."


He then carries the child into the center of the nave, as he says, "I will go into Thy House. I will worship toward Thy Holy Temple in fear of Thee." Stopping in the center, he says, "The servant of God  (Name)  is churched, in the Name of the Father, and of the Son, and of the Holy Spirit. Amen. In the midst of the congregation I will sing praises unto Thee."


He then walks up to the  iconostasis , and stopping in front of the  royal doors , he says, "The servant of God  (Name)  is churched, in the Name of the Father, and of the Son, and of the Holy Spirit. Amen."


He then carries the baby into the sanctuary and around the back of the  altar  and out again onto the  soleas .


He then chants the  Nunc dimittis  and says a special  apolysis  (dismissal) , after which he blesses the child with the Sign of the Cross on its forehead, mouth and heart, and returns it to its mother.


Cord blood  ( umbilical cord blood ) is  blood  that remains in the  placenta  and in the attached  umbilical cord  after  childbirth . Cord blood is collected because it contains  stem cells , which can be used to treat  hematopoietic  and  genetic disorders  such as  cancer .


Cord blood is composed of all the elements found in whole  blood  –  red blood cells ,  white blood cells ,  plasma ,  platelets . [ 6 ]  Compared to whole blood some differences in the blood composition exist, for example, cord blood contains higher numbers of  natural killer cells , lower absolute number of  T-cells  and a higher proportion of immature T-cells. [ 7 ]  However, the interest in cord blood is mostly driven by the observation that cord blood also contains various types of  stem  and  progenitor cells , mostly  hematopoietic stem cells . [ 6 ] [ 7 ] [ 8 ]  Some non-hematopoietic stem cell types are also present in cord blood, for example,  mesenchymal stem cells , however these are present in much lower numbers than what can be found in adult  bone marrow . [ 7 ] [ 8 ]   Endothelial progenitor cells  and  multipotent  unrestricted  adult stem cells  can also be found in cord blood. [ 8 ]  Unlike  embryonic stem cells  which are  pluripotent , cord blood stem cells are multipotent. [ 8 ] [ 9 ] [ 10 ]


Cord blood is used the same way that  hematopoietic stem cell transplantation  is used to reconstitute bone marrow following radiation treatment for various blood cancers, and for various forms of  anemia . [ 11 ] [ 12 ]   Its efficacy is similar as well. [ 11 ]


Adverse effects are similar to hematopoietic stem cell transplantation, namely  graft-versus-host disease  if the cord blood is from a genetically different person, and the risk of severe infection while the immune system is reconstituted. [ 11 ]  To assure that the smallest amount of complications occur during transplantation, levels of engraftment must be present; specifically both neutrophils and platelets must be being produced. [ 13 ]  This process of neutrophil and platelet production after the transplant, however, takes much longer than that of stem cells. [ 13 ]  In many cases, the engraftment time depends on the cell dose, or the amount of stem cells obtained in the sample of blood. [ 13 ]  In Dr. Moise's article about umbilical cord blood, it was found that there is approximately 10% less stem cells in cord blood than there is in bone marrow. [ 13 ] [ 14 ]  Therefore, a sufficient amount of cord blood must be obtained in order to collect an adequate cell dose, however this amount varies from infant to infant and is irreplaceable. Given that this idea is quite new, there is still a lot of research that needs to be completed. For example, it is still unknown how long cord blood can safely be frozen without losing its beneficial effects. [ 13 ]  There is a lower incidence with cord blood compared with traditional HSCT, despite less stringent HLA match requirements. [ 11 ]


Umbilical cord blood is the blood left over in the placenta and in the umbilical cord after the birth of the baby. There are several methods for collecting cord blood. The method most commonly used in clinical practice is the "closed technique", which is similar to standard blood collection techniques. [ 15 ]  With this method, the technician  cannulates  the  vein  of the severed umbilical cord using a needle that is connected to a blood bag, and cord blood flows through the needle into the bag. On average, the closed technique enables collection of about 75 ml of cord blood. [ 16 ]


Collected cord blood is  cryopreserved  and then stored in a  cord blood bank  for future transplantation. Cord blood collection is typically depleted of red blood cells before cryopreservation to ensure high rates of stem cell recovery. [ 17 ]


The first successful cord blood transplant (CBT) was done in 1988 in a child with  Fanconi anemia . [ 11 ]  Early efforts to use CBT in adults led to mortality rates of about 50%, due somewhat to the procedure being done in very sick people, but perhaps also due to slow development of immune cells from the transplant. [ 11 ]  By 2013, 30,000 CBT procedures had been performed and banks held about 600,000 units of cord blood. [ 12 ]


Hemacord (HPC, cord blood) was approved for medical use in the US in 2011. [ 5 ] [ 18 ]


Ducord (HPC Cord Blood) was approved for medical use in the US in 2012. [ 4 ] [ 19 ]


Allocord (HPC Cord Blood) was approved for medical use in the US in 2013. [ 1 ] [ 20 ]


Cordcyte was approved for medical use in the US in 2013. [ 3 ]


Clevecord (HPC Cord Blood) was approved for medical use in the US in 2016. [ 2 ] [ 21 ]


Regenecyte (HPC, Cord Blood) was approved for medical use in the US in November 2024. [ 22 ] [ 23 ]


The  AABB  has generated voluntary accreditation standards for cord blood banking facilities. [ 24 ]


In the United States, the  Food and Drug Administration  regulates any facility that stores cord blood; cord blood intended for use in the person from whom it came is not regulated, but cord blood for use in others is regulated as a drug and as a biologic. [ 25 ]  Several states have regulations for cord blood banks. [ 24 ]


In the European Union, Canada, and Australia use of cord blood is regulated. [ 24 ]  In the United Kingdom, the NHS Cord Blood Bank was set up in 1996 to collect, process, store and supply cord blood; it is a public cord blood bank and part of the NHS. [ 26 ]


A cord blood bank may be private (i.e. the blood is stored for and the costs paid by donor families) or public (i.e. stored and made available for use by unrelated donors).  While public cord blood banking is widely supported, private cord banking is controversial in both the medical and parenting community.  Although umbilical cord blood is well-recognized to be useful for treating hematopoietic and genetic disorders, some controversy surrounds the collection and storage of umbilical cord blood by private banks for the baby's use.   Only a small percentage of babies (estimated at between 1 in 1,000 to 1 in 200,000) ever use the umbilical cord blood that is stored. [ 27 ]   The American Academy of Pediatrics  2007 Policy Statement on Cord Blood Banking stated: "Physicians should be aware of the unsubstantiated claims of private cord blood banks made to future parents that promise to insure infants or family members against serious illnesses in the future by use of the stem cells contained in cord blood."  and  "private storage of cord blood as 'biological insurance' is unwise" unless there is a family member with a current or potential need to undergo a stem cell transplantation. [ 27 ] [ 28 ]   The American Academy of Pediatrics also notes that the odds of using a person's own cord blood is 1 in 200,000  while the  Institute of Medicine  says that only 14 such procedures have ever been performed. [ 29 ]


Private storage of one's own cord blood is unlawful in Italy and France, and it is also discouraged in some other European countries. The  American Medical Association  states "Private banking should be considered in the unusual circumstance when there exists a family predisposition to a condition in which umbilical cord stem cells are therapeutically indicated. However, because of its cost, limited likelihood of use, and inaccessibility to others, private banking should not be recommended to low-risk families." [ 30 ]  The American Society for Blood and Marrow Transplantation and the  American Congress of Obstetricians and Gynecologists  also encourage public cord banking and discourage private cord blood banking. Nearly all cord blood transplantations come from public banks, rather than private banks, partly because most treatable conditions can't use a person's own cord blood. [ 31 ] [ 27 ] [ 28 ] [ 32 ]   The World Marrow Donor Association and European Group on Ethics in Science and New Technologies states "The possibility of using one's own cord blood stem cells for regenerative medicine is currently purely hypothetical....It is therefore highly hypothetical that cord blood cells kept for autologous use will be of any value in the future" and "the legitimacy of commercial cord blood banks for autologous use should be questioned as they sell a service which has presently no real use regarding therapeutic options." [ 33 ]


The  American Academy of Pediatrics , or AAP, supports efforts to provide information about the potential benefits and limitations of cord blood banking and transplantation so that parents can make an informed decision. [ 34 ]  Cord blood education is also supported by legislators at the federal and state levels. In 2005, the National Academy of Sciences published an Institute of Medicine (IoM) report titled "Establishing a National Cord Blood Stem Cell Bank Program". [ 35 ]


In March 2004, the European Union Group on Ethics (EGE) has issued Opinion No.19 titled  Ethical Aspects of Umbilical Cord Blood Banking . [ 36 ]  The EGE concluded that "[t]he legitimacy of commercial cord blood banks for autologous use should be questioned as they sell a service, which has presently, no real use regarding therapeutic options. Thus they promise more than they can deliver. The activities of such banks raise serious ethical criticisms." [ 36 ]


Though uses of cord blood beyond blood and immunological disorders is speculative, some research has been done in other areas. [ 37 ]  Any such potential beyond blood and immunological uses is limited by the fact that cord cells are  hematopoietic  stem cells (which can differentiate only into blood cells), and not  pluripotent  stem cells (such as  embryonic stem cells , which can differentiate into any type of tissue). Cord blood has been studied as a treatment for diabetes. [ 38 ]  However, apart from blood disorders, the use of cord blood for other diseases is not in routine clinical use and remains a major challenge for the stem cell community. [ 37 ] [ 38 ]


Along with cord blood,  Wharton's jelly  and the  cord lining  have been explored as sources for  mesenchymal stem cells  (MSC), and as of 2015 had been studied in vitro, in animal models, and in early stage clinical trials for cardiovascular diseases,  as well as  neurological deficits, liver diseases, immune system diseases, diabetes, lung injury, kidney injury, and leukemia. [ 39 ] [ 40 ] [ 41 ]


Cord blood is being used to get stem cells with which to test in people with  type 1 diabetes mellitus . [ 42 ]  The stem cells from umbilical cord blood are also being used in the treatment of a number of blood diseases including blood cancers. [ 43 ]


Cord blood is also being studied as a substitute for normal  blood transfusions  in the developing world. [ 43 ] [ 44 ]  More research is necessary prior to the generalized utilization of cord blood transfusion. [ 43 ]


Cord blood stem cells are being studied for treatment for COVID-19  cytokine storms  since these and other perinatal (cord tissue and placental tissue derived) stem cells can secrete anti-inflammatory molecules. Dozens of clinical trials are under way to see if they can help patients with  COVID-19 . [ 45 ]


Some clinical studies show that one year after the transplant of UM171 (a haematopoietic stem cell self-renewal agonist), transplant-related mortality was 5% and relapse incidence was at 21%. Furthermore, only 3 of 22 patients (~14%) who received the UM171-expanded cord blood transplantation died. [ 46 ] [ 47 ]


A woman was reported to have been cured of  human immunodeficiency virus  (HIV), the third person ever to be cured of the disease, using a transplantation of cord blood. [ 48 ]


A painted  desco da parto  (a  birth tray  or  birth salver ;  pl. :  deschi da parto ) was an important symbolic gift on the occasion of a successful birth in late medieval and  Early Modern   Florence  and  Siena .  The surviving painted  deschi  represented in museum collections were commissioned by elite families, but inventories show that birth trays and other special birth objects like embroidered pillows were kept long after the successful birth in families of all classes: when  Lorenzo de' Medici  died, the inventory shows that the  desco da parto  given by his father to his mother,  Lucrezia Tornabuoni , at her  lying-in , [ 1 ]  was hanging in his private quarters to the day of his death. [ 2 ]


A  desco da parto  need not have been specially commissioned; they were produced in workshops in series for stock, often being personalised with a  coat-of-arms  when they were bought.  There was a distinctive repertoire of  iconography  for the trays, the  recto  (top) sides sharing much with that for the painted  cassone  chests often used as gifts at marriage, but also with  verso  (bottom) sides often showing scenes of mothers after  childbirth  or pin-up figures of boy toddlers, accompanied by the coats of arms of both parents.  After being used as a tray during the period of  postpartum confinement , they could be hung on a wall as a painting.


Infant mortality  was highest during the crucial first days, when the mother might also succumb to  childbed fever . A successful childbirth was lavishly celebrated. Sons would one day assert the family interests, whether in modest workshop or banking house; daughters would share the household's work until they were married and would cement the   exogamous ties  that stabilized Tuscan family position at every social level. Painted childbirth trays began to appear about 1370, in the generation following the  Black Death , when the tenuousness of life was more vivid than ever. [ 3 ]  In the fifteenth century, D.C. Ahl found, at least one appears in almost half of all inventories she surveyed. [ 4 ]


The mother was expected to remain " lying in ", enjoying  bed rest  during a  postpartum period  of variable duration, but probably lasting at least a week. No fixed term of lying-in is recommended in Renaissance manuals on family life (unlike in some other cultures, see  Postpartum confinement ), but it appears from documentary records that the mother was rarely present at the  baptism , in Italian cities usually held within a week of the birth at the local  parish church , normally a few minutes' walk from any house.  During this period the mother and child were visited in the bedroom by family and female friends, and presented with gifts. [ 5 ]   The tray or  salver , often covered with a protective cloth, was used for serving delicacies to the visitors, perhaps including some they had brought as presents: a maid brings a cloth-covered  desco  with two carafes of water and wine to fortify  Saint Anne  in  Paolo Uccello 's fresco of the  Birth of the Virgin  (1436), in the Chapel of the Annunciation, Duomo of Prato, [ 6 ]


Raiment might be ceremoniously brought into the specially-decorated  bedchamber  where the new mother lay: in  a  desco da parto  by Masaccio  of 1427, [ 7 ]  the tray and a covered cup are preceded by a pair of trumpeters flying banners with the Florentine  gigli . In fact, in patrician households the bed was often placed in a reception room for the occasion (if there was not one already in such a room, after the fashion of the French and  Burgundian courts ), and the mother lay there while receiving visits from her friends over several days.


For the painted trays made for the elite on these joyous occasions, in general, both sides of the tray are painted, the upper side (or  recto ) generally with a crowded figure scene, usually secular, such as a scene from  classical myth  or a suitable  allegory .  Scenes from the  Old Testament  or the Christian religious repertoire also appear in some cases.  Birthing scenes were popular.  These might be the  Birth of the Virgin  or that of Florence's patron saint,  John the Baptist , but only a halo or two distinguishes these from other scenes apparently showing a birth scene as a  genre painting . A tray in the  New York Historical Society  shows a genre birthing scene but is closely copied from a drawing of the birth of John the Baptist by  Lorenzo Monaco . [ 8 ]


In all these the mother sits up in bed receiving gifts from a stream of female visitors, while at the front of the scene the child is washed or wrapped in  swaddling  by more women.  In one male pageboys serve the guests.  Another tray shows boys and men playing a local fighting game in the street (see gallery).  The earliest painted illustration of a  novella  of  Boccaccio  is on a Florentine  desco da parto  with the arms of a Pisan family, made c. 1410 and in the Metropolitan Museum of Art. [ 9 ]  The survivals include three allegorical scenes of the  Triumph of Love , derived from  Petrarch 's  Triumphs , and one  Triumph of Venus .


The underside or  verso  generally has a simpler and often less elevated subject, with fewer, larger figures, and usually includes  heraldry , with the arms of both parents shown. [ 10 ]   Scenes with one or two naked boy toddlers, with the  coats of arms  of both parents at the sides, are especially popular.  The arms of the mother's family traditionally take the right hand side, but in some examples the arms have been changed by overpainting them. [ 11 ]   Inscriptions in the field or round the rim sometimes provide the date of the fortunate event, [ 12 ]  providing art historians with a useful fixed point.  Like some other types of art, such as the  "Otto prints" , desci were mostly expected to be decorated in what was considered to be feminine taste, although how the design was selected is unclear.  In an example painted by  Masaccio's brother  two boys wrestle, with certainly one and probably both using the hold of pulling on the other's penis with one hand and hair with the other (see gallery). [ 13 ]


In the Renaissance it was believed that the sights a pregnant woman saw affected her pregnancy and even what it produced –  Martin Luther  told the cautionary story of a woman frightened by a mouse in pregnancy, who then gave birth to a mouse. Manuals advised keeping images with a positive impact in the sight of pregnant women, and it is in this context that the recurrent naked boys, and the scenes showing the end of a successful childbirth, should be seen.  This was also a factor in the display of images of the  Virgin and Child , which were ubiquitous in bedrooms. [ 14 ]  Probably the desci were hung with the verso displayed during pregnancy, to promote the production of a similar healthy boy.


Workshops that produced  deschi da parto  were often also  manuscript illuminators , as for example  Bartolomeo di Fruosino , an illuminator who also produced panel paintings, and painters of the panels that were incorporated into the fronts and ends of  quattrocento   cassoni . Such a workshop was that of the "Master of the Adimari cassone", now usually identified as Masaccio's brother  Giovanni di ser Giovanni Guidi  (or "Lo Scheggia", "the Splinter"), which also produced the  desco da parto  showing youths playing at  civettino  in an urban setting, in  Palazzo Davanzati , Florence, [ 15 ]  and other examples.  A divided verso showing two naked boys fighting realized $482,500 at auction in 2012. [ 16 ]


Some artists remain unidentified, and were clearly not of the first rank, but, given the significant names represented among the tiny proportion of survivors, it appears that many artists took an occasional break from larger projects to produce  desci .  The circular  tondo  shape in normal  panel paintings , which became fashionable in the mid-fifteenth century in Florence, may have developed from the smaller desci. [ 17 ]


The format of the desco, usually about 50 to 60 cm across, is with twelve or sixteen sides, or from about 1430, round, [ 18 ]  enclosed within a slightly raised lip integral to the panel.  Some examples that are now round seem to have originally been twelve-sided.  Some have dates that record the day of the birth (or marriage) concerned. Only about two dozen desci survive, some now with the surfaces sawn apart by dealers in modern times, to create two works. [ 19 ]  In inventories they are often described as "broken" or "old", and most apparently were used as trays until too scruffy to keep.  As the 15th century continued they were gradually replaced as gifts by pieces of  majolica , often special "birthing sets" with similar iconography, although the  Uffizi  has an example of 1524 by  Jacopo Pontormo , and others are even later. Examples from the 16th-century tend to have a more raised bowl-like profile, as in the Pontormo, as if echoing the new maiolica shapes.  Production of painted cassoni ceased over the same decades.


Jacqueline Marie Musacchio rejects the common assumption that these trays were made to celebrate a marriage; she never encountered a  desco da nozze  in any 15th-century inventory. [ 20 ]   But a Sienese wedding casket ( cofanetto nuziale ) in wood in the Louvre has a round top with a  Triumph of Venus  by  Giovanni di Paolo  (dated 1421) that is effectively identical to the desci form. [ 21 ]   Nevertheless, if they were presented at the time of the marriage, though certainly regarded as associated specifically with pregnancy and childbirth, this would both explain how such elaborate objects were available for use very soon after an uncertain event, and mean that the beneficial images of boys could exert their positive influence throughout the important first pregnancy.


Other types of secular Italian Renaissance art designed for female tastes are the marriage caskets made by the  Embriachi workshop  and others, and the  Otto prints  for lids and covers of boxes.


The  San Francisco Legion of Honor Museum  has an example painted about 1400 by  Lorenzo di Niccolo , a Florentine painter who was active from 1391 to 1412.  The recto shows the story of  Diana  and  Actaeon .  Diana, goddess of hunting appears in the foreground clothed in a dark, brocaded robe and carrying a falcon; at the right, her nymphs pursue a boar. At the top of the painting, Diana and her nymphs are bathing in a pool of water when the mortal Actaeon happens upon the naked goddess. For offending the virgin deity, Actaeon was transformed into a  stag  to be hunted down by his own dogs. His fate is illustrated on the left side, where hounds chase a deer.  The reverse (verso) shows the allegorical figure of Justice with two family coats of arms while holding a scale and a sword. [ 22 ] [ 23 ]


DONA International  (formerly  Doulas of North America ) was founded in 1992 and is the first and largest  doula  training and certification organization. [ 1 ]  The current president of the non-profit is Dr. Robin Elise Weiss. [ 2 ]


In the 1980s,  Dr. Marshall Klaus ,  Dr. John H. Kennell , Phyllis Klaus,  Penny Simkin  (1938–2024), [ 3 ]  and Annie Kennedy first formed a partnership of doulas and medical professionals. [ 4 ] [ 5 ]  Klaus (1927–2017), [ 6 ]  a  neonatologist , and Kennell (1922–2013), [ 7 ]  a  pediatrician , gave credibility to doulas Phyllis Klaus, Simkin, and Kennedy [ 8 ]  by supporting their work through the research of  parent-child bonding  in the 1960s at  Case Western Reserve University . [ citation needed ]


Doulas Of North America (DONA) was formally founded in 1992 and the organization was the first of its kind to both train and certify the non-medical birth support of doulas and marked the start of professional doulas on a nationwide basis. [ 4 ] [ 5 ]  Kennedy (who had originally founded the Pacific Association of Labor Support in 1989 in Seattle, WA with Simkin alongside the doula training at Seattle Midwifery School) become  [ 9 ]  the first president of the organization. [ 8 ]


In 2004, the organization re-branded as DONA International. [ 4 ]


By 2016, there were 12,000 doulas certified through the organization. [ 1 ]


DONA International offers  birth  and  postpartum  doula training and certification. [ 10 ]  To certify as a doula, an in-person, virtual, or hybrid workshop is mandatory, along with supplementary text reading, lactation training and childbirth education, and clients experience. [ 11 ]  The workshop is taught by approved trainers who are able to the required coursework which includes emotional support, physical support or comfort measures, communication, interventions, ethics and professional behavior. [ 12 ]


DONA International has numerous advocacy areas:


A  doula  ( / ˈ d uː l ə / ; from  Ancient Greek    δούλα  'female slave';  Greek pronunciation:   [ˈðula] ) is a non-medical professional who provides guidance for the service of others and who supports another person (the doula's client) through a significant health-related experience, such as  childbirth ,  miscarriage ,  induced abortion  or  stillbirth , as well as  non-reproductive experiences such as  dying . [ 1 ] [ 2 ] [ 3 ] [ 4 ]  A doula might also provide support to the client's partner, family, and friends. [ 5 ] [ 6 ]


The doula's goal and role is to help the client feel safe and comfortable, complementing the role of the healthcare professionals who provide the client's medical care. Unlike a physician,  midwife , or nurse, a doula cannot administer medication or other medical treatment or give medical advice. [ 7 ] [ 2 ]  An individual might need to complete training to work as a doula, although training and certification processes vary throughout the world. [ 7 ] [ 3 ] [ 4 ] [ 8 ]


Some doulas work as volunteers; others are paid for their services by their client, medical institutions, or other private and public organizations. Doulas receive varying amounts of training, and their professionalism also varies. [ 4 ] [ 9 ]


The contributions of doulas during reproductive experiences and end-of-life care have been studied and have been shown to benefit their clients. [ 4 ] [ 10 ] [ 11 ] [ 12 ]  For example, a birth doula providing support during  childbirth   might increase likelihood of vaginal birth (rather than  Caesarean section ), decrease the need for pain medication during labor, and improve the perception of the birthing experience. [ 13 ] [ 14 ]


The benefits of a doula providing other types of support have been less well studied, but might improve a client's experience with medical care or help an individual cope with health transitions. [ 15 ] [ 16 ] [ 4 ] [ 17 ]


The concept of having a companion providing support to the birthing woman dates back to prehistoric times, evidenced by archeological findings of stone carvings and statues and anthropological studies. [ 18 ]  However, the contemporary role of "doula" first emerged from the grassroots  natural birth movement  in the United States in the 1960s when women began desiring unmedicated, low-intervention births and began to have friends and others with formal or practical knowledge about childbirth provide them with support during pregnancy. [ 19 ]


The term  doula  was first used in a 1969  anthropological study  conducted by  Dana Raphael , a protégée of  Margaret Mead , with whom she co-founded the Human Lactation Center in  Westport, Connecticut , in the 1970s. [ 20 ]  Raphael suggested it was a widespread practice that a female of the same species be part of childbirth, and in human societies this was traditionally a role occupied by a family member or friend whose presence contributed to successful long-term breastfeeding. [ 20 ]  Raphael derived the term from  modern Greek  ( δούλα ,  doúla  ( Greek pronunciation:   [ˈðula] ), "slave" [ 21 ] ), as told to her by an elderly Greek woman, [ 22 ]  Eleni Rassias, [ 23 ]  and described it as coming from " Aristotle 's time," an  Ancient Greek  word  δούλα  meaning "female slave." [ 24 ]


Two physician-researchers,  Marshall Klaus  and  John Kennell , who conducted  clinical trials  on the medical outcomes of doula-attended births, adopted the term to refer to a person providing labor support. [ 7 ]  In 1992,  Doulas of North America  (later DONA International) was co-founded by Klaus, Kennell, Phyllis Klaus, Penny Simkin, and Annie Kennedy, becoming the first organization to train and certify doulas. [ 25 ] [ 26 ]  The organization with the backing of the research of Klaus and Kennell helped lend credibility and professionalize doulas. [ 27 ]  Due to the lobbying efforts of DONA International, the term  doula  was accepted into the  American Heritage Dictionary  and  Oxford Dictionary  in 2003, followed by  Merriam Webster Dictionary  in 2004. [ 26 ]  Alternative names to this role include "childbirth assistant" and "monitrice," but they did not catch on as "doula" had. [ 19 ]


In 2008, activists in New York City began the Doula Project, to expand the role of the doula to other reproductive experiences beyond birth, grounded in  reproductive justice  framework. [ 28 ] [ 29 ]  The participants began working as abortion doulas and coined the term "full-spectrum doula" who support all pregnancy experiences and outcomes such as pregnancy termination, miscarriage and fetal loss. [ 28 ] [ 30 ]  Full spectrum doula groups can be found in major cities in the United States. [ 31 ]


In 2019,  Black maternal health  advocate and  Parents  writer  Christine Michel Carter  interviewed Vice President  Kamala Harris  about the popularity of doulas in the Black community. [ 32 ]  As a senator, in 2019 Harris reintroduced the Maternal Care Access and Reducing Emergencies (CARE) Act which aimed to address the maternal mortality disparity faced by women of color by training providers on recognizing implicit racial bias and its impact on care. Harris stated:


"We need to speak the uncomfortable truth that women—and especially Black women—are too often not listened to or taken seriously by the health care system, and therefore they are denied the dignity that they deserve. And we need to speak this truth because today, the United States is 1 of only 13 countries in the world where the rate of maternal mortality is worse than it was 25 years ago. That risk is even higher for Black women, who are three to four times more likely than white women to die from pregnancy-related causes. These numbers are simply outrageous."


A doula focused on birth is also known as a birth companion, nonclinical birth worker, birth coach, or post-birth supporter, by providing continuous care before, during, or after in the form of information, advocacy, physical support, and emotional support. [ 2 ] [ 14 ] [ 8 ] [ 10 ]  A birth doula is also called a labor doula. A birth doula might accompany a pregnant woman during labor and birth in place of or in addition to a partner, family member, or friend. Unlike these other birth companions, a doula has formal training in labor support. [ 2 ] [ 14 ]  The kinds of support provided during childbirth might include physical assistance and comfort (massage, maintaining a supporting posture, or providing water), emotional support (providing company, encouragement or simply talking in a soothing tone of voice), acting as an advocate during childbirth (supporting the birthing woman's right to make decisions about their own body and baby to the medical team) and informational support (provide information about the birthing process and non-medication based forms of pain relief, and facilitating communication between their client and health providers). [ 14 ] [ 5 ]


Most doula-client relationships begin a few months before the baby is due. Before the labor, the doula and the family can develop a relationship where the pregnant woman and their support person (e.g. the other parent) feel comfortable asking questions, expressing their fears and concerns, and discussing birth preferences. [ 24 ]


Continuous support during labor provided by doulas has been associated with improved outcomes for both birthing women and babies, including shorter delivery, fewer  cesarean sections  and complications, the use of fewer  medications  and fetal extraction tools, less time in  neonatal intensive care units , positive psychological benefits, more satisfying birth experiences, and increased  breastfeeding . [ 11 ] [ 5 ]  Cross-country research on the effects of doulas on childbirth and postnatal care is complicated by the variety of settings, cultures, and medical systems of individual countries and the characteristics of patients. These benefits appear to be contingent on the doula providing continuous rather than intermittent assistance and knowing the specific social and cultural setting within which their services are provided. [ 33 ]  Doula care can help reduce  health disparities  of those with the greatest need including those with less education, lower incomes, less preparation for childbirth and those lacking social support. [ 34 ] [ 35 ] [ 36 ] [ 37 ]  Research also supports the effectiveness of female friends or relatives, after minimal training, as a low-cost alternative to professional doulas. [ 11 ] [ 38 ]


In March 2014, the  American College of Obstetricians and Gynecologists  (ACOG) put out a Consensus Statement titled "Safe Prevention of Primary Cesarean Delivery" in which it said, "Increasing [a woman's] access to non-medical interventions during labor, such as continuous labor support, also has been shown to reduce cesarean birth rates." [ 39 ]  As more research has become available on the positive benefits of trained labor support provided by someone not employed by the hospital, in 2017 ACOG officially announced the need for all birthing individuals to have access to continuous labor support outside hospital staff, and said, "Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes." [ 40 ] [ 41 ]  The official committee opinion put out by ACOG also offers other recommendations that allow birthing women more choice and access to more supportive care. Doulas could be utilized to help achieve many of these recommendations as they move towards better collaboration. [ 42 ]


In 2017 the United Kingdom's  Royal College of Midwives  published a position statement on doulas, which supports the choice of the individual to hire a doula for their birth as long as the doula does not provide medical care. [ 43 ]


A 2018 study examined women's perceptions of doulas in several different countries, including Egypt, Lebanon, Syria, Malawi, Sweden, Nepal, Russia, Canada, and the United States of America and found that having continuous support from a companion such as a doula was highly appreciated by most women. [ 10 ]  However, perceptions may vary from country to country due to cultural factors, such as an emphasis on modesty and privacy, which might affect what kind of support a woman prefers. [ 10 ]


A 2018 study examining news media discourse in China noted that Chinese doulas needed to register with official departments or organizations and are closely linked with midwifery. The doula profession was introduced in 1996 to mainland China and demand of their services increased since then, with women citing dissatisfaction with medical care. After China's implementation of the Second-Child Policy, doula care was strongly linked to doula support in regard to family planning. [ 44 ]


Tensions between doctors, nurses, and doulas have sometimes been described as a "turf battle," [ 45 ]  though it is also recognized that doulas and nurses can occupy complementary roles that provide opportunities for mutual learning and assistance. [ 46 ]  Some hospitals have created internal doula training programs to reduce conflict between doulas and medical staff. [ 45 ] [ 47 ]


There is no law requiring doulas to become certified, however, certification can benefit professional doulas by providing structured education prior to entry into the field, access to a mentor, opportunities for networking, and client confidence. [ 48 ]  In  North America , training generally takes the form of a two- to the three-day seminar, and some experience with childbirth. [ 49 ]  Trainees might have hands-on practice with various techniques used during childbirth, including maternal positions and movements, relaxation and breathing exercises and other measures that could be used for comfort. Certification can occur through organizations at various levels (local, national, or international) and some require positive evaluations from medical professionals. Certification may also require, in addition to attending a training course, time spent working or learning about maternity care and childbirth classes, and possibly a written exam. [ 17 ]  Some doulas train through distance education. [ 46 ]