IT WASN'T UNTIL Erica Kain was a day past her due date that she decided she was woefully unprepared for the birth of her baby.

There she was, driving down Highway 24 alongside her sister, who'd just arrived in town to lend a hand for the big day, when the realization struck.

"We were talking in the car, and it occurred to me that my sister had no real experience with birth. Whatsoever," says Kain. "My nervous sister was nowhere near the energy I needed in that birth room. I needed someone who'd been through a birth before. Someone who had experience."

To say that Kain pulled the car to a screeching halt, "Starsky and Hutch" style, isn't too far from the truth. And after she parked, she marched, as quickly as the extra 50 pounds on her body and the baby in it would allow, into Lafayette's Nurture Center.

Kain wanted a birth doula. And she wanted one right away.

"It just occurred to me right then," says Kain, 34, "that a birth doula would be the right thing to have."

Doulas are quite possibly the quintessential Bay Area birthing accoutrement: They bear an exotic name that sounds somewhat granola-esque. They often use meditative and holistic techniques. And a portion of the hard-core medical community can't stand them.

Talk about hitting all the requirements for a liberal-loving, left-coast population.

"Doulas are more popular than they've ever been, and probably more popular here than anyplace else," says Betsy Appell, 38, a Berkeley doula who's been practicing for four years and is booking up to six months in advance. "I can't say why. All I can say is that the doula is for the woman, not so much the baby. The more relaxed the woman, the easier the birth."

Named after the Greek word for slave, doulas are, basically, personal assistants for expectant parents that come in two flavors. Birth doulas sit by the mother's side during delivery, helping her through labor by massaging her back or suggesting alternate positions, making an increasingly medical world just a bit more personal. Post-partum doulas care for the mother at home after the baby is born, taking on a role a grandmother might, making our increasingly fragmented families seem just a bit more whole.

Qualifications vary

How doulas work varies as much as their fee schedules, which range from $250 to $1,400. Some doulas, like Appell, who lived for a time in a Buddhist monastery, have extensive Zen training and are certified. Others have no certification but have attended hundreds of births and have clients swear on their children's lives by them.

Don't confuse a doula with a midwife. A doula's focus is the emotional and physical well-being of the mother. A midwife's concern is the health and well-being of the fetus, in addition to the mother.

"Being a doula is more about being than doing," says Sharon Craig, 23, who used to be a doula in the Bay Area but is now a certified clinical midwife in Kabul, Afghanistan. "It amazed me how, after births, women would lavish me with all sorts of comments like 'I could never have done it without you,' when I felt I wasn't really doing much. But the main thing for women in labor is for them to have someone who is focused entirely and solely on them. They know that their doula will not leave them."

It's not all just earthy, touchy-feely hocus-pocus either. Statistics assembled by DONA International (formerly known as Doulas of North America), an organization that trains and certifies doulas, give pause. According to studies in North America, Europe and Africa, women cared for during labor by a birth doula, compared to those receiving "usual care," were 26 percent less likely to have Caesarean sections; were 41 percent less likely to give birth with a vacuum extractor or forceps; were 28 percent less likely to use any "drugs," such as an analgesic or anesthesia; and were 33 percent less likely to be dissatisfied or negatively rate their birth experience.

Those stats are key because doulas are traditionally hired by women seeking natural childbirths. After all, that's what swayed Kain toward getting a doula, even as late as one day after her due date.

"I didn't decide I wanted to commit to natural childbirth until that day in the car. But we were in no way prepared," says Kain. "Yes, we'd gone to a women's center for classes about childbirth, but they were just not that useful. At one point they had (my husband) hold an ice cube in his hand and said, 'That's what a contraction is like.' He didn't get it. He just held it in his hand until it melted. That was the extent of our preparation."

When Kain remembered a friend of hers in San Diego had gone through natural childbirth twice using a doula, she hired one immediately. That doula ended up being Deanna Jesus, who was working part-time inside Lafayette's Nurture Center the day Kain's car came screeching to a halt out front.

"She ended up coaching me through the final part of my labor," says Kain. "The second my eyes laid on her, wham! I knew we were going to be OK and get through it. I never lost that faith."

Along with the growing popularity of doulas, though, has come a broader clientele. Today, not all women desiring a doula's assistance want a natural childbirth. They primarily want someone who's been through births before in today's HMO world.

"So many women are scared of giving birth — and there's just no familiarity anymore in the process," says Jesus, 42. She's based in San Ramon and has a personalized license plate that reads "(heart)DOULAS." "Oh my gosh — the way the medical system is set up now, you don't know who's going to be in the room at all."

That very fear is what spurred Elena Mendelson to search out Jesus, who eventually served as her doula. Not wanting a natural childbirth, Mendelson never considered a doula because she thought they were all about holistic approaches. But as the birth neared, she got the jitters. A friend who did not have a natural childbirth but did have a doula said it would help ease her anxiety.

"I can't even imagine how I would have proceeded without her," says Mendelson, 32. "I did not realize the nurses are not by your side the whole time, that they just come and go. And even though my husband is sitting there, he doesn't know what's going on either. We needed to know someone who knew the system better than we did. The benefit was better than we anticipated — ultimately I did not use the epidural. And I think it was because of Deanna."

Some debate over doulas

But doulas aren't embraced universally. They aren't welcome in hospitals in some parts of the country, and even in the Bay Area, there is some friction between the medical community and the doula work force. To wit: California Pacific Medical Center in San Francisco only allows pre-approved doulas to assist in births, while the Palo Alto Medical Foundation doesn't permit doulas in their Palo Alto clinic at all.

While we tried to contact both CPMC and PAMF physicians for comments, only this came from Shannon Rolf, a spokesperson for PAMF. Explaining that the doula policy varies depending on the clinic within the PAMF, she said the Fremont, Los Altos and Portola Valley clinics allow families to use doulas.

"At the Palo Alto Medical Foundation, each OB/GYN physician makes his or her own decision on whether or not to work with doulas," Rolf offered in an e-mail concerning the policy. "We have physicians who do work with doulas and physicians who do not. It comes down to each physician and his or her practice philosophy."

The friction over doulas apparently arose because doulas advocating natural births and spurning common medical procedures have on occasion endangered healthy births. Doctors wanting to administer an epidural or have the mother take Pitocin to help labor progress faster have been stonewalled by a doula dead set on achieving birth naturally, even though a longer labor was risking the health of the not-yet-born baby.

Even the most common practice of the doula — having the woman wait as long as possible to go to the hospital so they can remain more comfortable at home, during early contractions — has sometimes backfired. Doulas rely on familiar cues, not physical examinations, to know when their clients are close to birth and need a doctor's care. But sometimes that's not enough, as Appell, the Berkeley doula, once found out during a birth that, thankfully, didn't have an adverse outcome.

"I had one patient, and neither of us could tell she was having contractions at all," says Appell. "We went for a long walk, she paused once, rubbed her back, and I asked 'Is that a contraction?' And she said she didn't think so. So I said, 'Go back home, it's really early.' The next time they called me they were on their way to the hospital. She was all ready to go. I still thought she was really, really early."

Fathers, too, can be hesitant to embrace having a doula at their child's birth. Janna Schultz, who used a doula in April 2005 for the birth of her son Christian, said her husband, Paul, was afraid a doula would squeeze him out of the birthing room.

"My husband was a little leery," says Schultz, 33, of San Ramon. "Like a lot of men, he felt like a doula might replace him."

That said, the future of the doula, at least for the moment, seems secure. Less a fad along the lines of those once ubiquitous "Baby on Board" signs, and more an outgrowth of a modern health care system that lacks the human touch, doulas are probably in for a robust future.

Especially as there will never be a lack of first-time parents.

"I think doulas are perfect for those paranoid parents who want a more controlled approach to childbirth," says Mendelson, who says she won't use a doula for the birth of her second child because it will be a scheduled c-section. "It's nice to know what's going on. And to cover your bases."

You can e-mail Candace Murphy at cmurphy@angnewspapers.com or call (925) 416-4814.

HERE ARE some questions you should ask before hiring a doula.
1. Is the doula certified?
2. Does the doula provide prenatal and/or post-partum visits?
3. How many births has the doula attended?
4. Can the doula provide references? Get the references and check them. Mothers who have been through the process are extremely honest — sometimes more so than their doulas might want them to be.
5. Is the doula open to medical intervention? For women not seeking natural births, this is important.
6. What's the doula's fee? A doula seeking certification but needing births for experience may not charge. A well-seasoned doula can cost as much as $1,400.
7. Has the doula worked at the location where you plan to give birth? Some clinics and hospitals do not allow doulas.
8. Does the doula have a back-up plan if she's not available?
9. How does the doula define her role during labor and birth?
10. Do you AND your partner like the doula?
— Candace Murphy