Overall, the adult and the combined sample of adolescent and adult doula-assisted mothers reported significantly greater percentages of breastfeeding initiation compared with their adult and combined adult and adolescent nondoula counterparts. The results show that expectant mothers matched with a doula had better birth outcomes than did mothers who gave birth without involvement of a doula. Doula-assisted mothers were four times less likely to have a LBW baby, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding.
With the exception of breastfeeding, comparison of adolescent and adult expectant mothers was not significantly different on these outcomes. Although it cannot be determined conclusively that having a doula was the reason for the greater likelihood of positive birth outcomes, this deserves a strong consideration because of the fact that the two groups of mothers were in most ways indistinguishable. They did differ in terms of with whom they were living prior to birth, with the doula group more likely to be living with partners or nonfamily others compared with the nondoula group who were far more likely to be living with family not including partners.
This difference, however, did not relate to higher frequencies of expected birth support for the nondoula mothers. This means that even though more of the doula-assisted mothers expected support from someone close to them at prebirth or birth, they also wanted to have additional support, which was provided to them by a doula. Although not collected systematically as part of this study, doulas and case managers reported that mothers who had a doula were positive about the support they received from doulas prior to the prenatal period and during labor and birth.
These reports underscore the value of doulas as sources of dependable and consistent support. Although the primary focus of this article was to report the positive impact on birth outcomes for an at-risk group of mothers, it is important to note that the doulas were not a completely independent source of information and support.
In these classes, participants learned about prenatal care; reproductive life planning; prenatal fitness and healthy nutrition; multivitamins and folic acid; and information on breastfeeding, healthy relationship formation, nutrition and cooking, stress management, and safe and secure housing. Doula- and nondoula-assisted mothers participated in the same childbirth classes. It is notable that despite participating in the same education classes, the women who chose to work with a doula had significantly better birth outcomes as measured by birth weight and fewer birth complications.
This finding suggests that women who embraced the premise that a doula may help empower them to influence their birthing experience, manage their labors more effectively, and reach their expectations and hopes for a positive, healthy birth also may have realized that they could improve their prenatal health and the likelihood of a healthy birth outcome through their active participation and engagement in the healthy prenatal activities offered by this program. Why some of the expectant mother chose to work with a doula, whereas others did not remains an open question.
One possibility is those who chose to work with a doula believed that it would enhance the information and support they were getting from the childbirth classes. Conversely, those who were not convinced that a doula could improve their birth experience may have also been less influenced by the other components of this program and the belief that their behavior changes could improve their chances for a healthy birth weight baby. Another possibility is that the women who chose doula support were most in need of support Gilliland, If this is true, then their significantly better birth outcomes are even more noteworthy.
Perhaps they did not have significant other people who were willing or able to help them during labor and birth. However, it is equally plausible that those who chose doula support were able to benefit from this support and reduced impact of factors associated with adverse birth outcomes. Because the doula group was more likely to be living on their own or with a partner, this might indicate they were more comfortable involving others outside of their family or support group.
These possible connections and potential for positive impact on birth outcomes warrant further investigation.
YWCA GREENSBORO HEALTHY BEGINNINGS DOULA PROGRAM
One limitation of this study is that participants self-selected themselves to work with a doula. Conceivably, expectant mothers who perceive the need or like the idea of having someone such as a doula assist them at the time they give birth are different than those who do not and take extra precautions for increasing the chance of a healthy birth.
In this study, the decision to work with a doula was likely as much a critical determinant of birth outcomes as defined by birth weight as the actual support activities the doula provided. Another limitation was that there was no information on who else was involved in providing support to the mothers leading up to birth. Finally, as noted, the doula involvement was not independent of other services and support received by program participants. Because the doulas were assigned to interested participants in the beginning of their involvement with this program, they had time to discuss the birthing experience and to bond with expectant mothers and to help them prepare for delivery and birth of the baby.
Doulas can empower women to achieve the best birth outcomes possible, and all outcomes—for births, infants, and mothers—seem to be affected more positively if support is provided by a doula in addition to the medical personnel.http://ctcopieur.com/orientalist-aesthetics-art-colonialism-and-french-north-africa.php
Impact of Doulas on Healthy Birth Outcomes
The doula focuses on individualized support before, during, and after birth; whereas nurses often are attending to several women in labor and responsible for many clinical and administrative tasks besides direct labor support. Hospitals could address this disparity by including a system of doula support.
Although all women in this program received education and support from staff and peers, the extra dimension of a doula may have increased the empowerment and motivation of women to improve their health prenatally. Women are motivated to have healthy babies. They are also motivated to have manageable labor and birth experiences. Women who embraced the idea that doula support could improve their locus of control in labor and birth may have increased and acted on their belief that their prenatal health behaviors would improve their birth outcomes Weisman et al.
HBDP is part of a complex of programs offered by the YWCA intended to help women increase not only their knowledge and practice of healthy prenatal behaviors but also their self-efficacy and informed decision making in developing and implementing healthy behaviors. The involvement of a doula seems to magnify the impact of these programs resulting in even better birth outcomes and birth experiences.
This study reinforces the case that doula involvement is a cost-effective method to improve outcomes for mothers and infants. Doula assistance in this case seems to have impacted health choices of expectant mothers during pregnancy, resulting in lower risk of LBW births. Doulas may have enhanced processing and internalization of the information presented in the group childbirth education classes. Support from a doula and the security of knowing she would be present at the birth may have reduced a measure of the stress and anxiety experienced by the mother. In light of these outcomes, practitioners should consider doulas as a part of an enhanced prenatal group care program to improve birth outcomes and involve them early in the pregnancy.
This study indicates that the inclusion of doulas in the prenatal period, at a point when behavioral changes can most impact birth outcomes, is most effective. Therefore, if obstetricians and other birthing professionals could include a plan of doula support in the prenatal period, adverse birth outcomes associated with a lack of social support or for women in general could be reduced. This would benefit the women and babies, medical practitioners, hospitals, and the greater community in reducing the financial and personal costs of adverse birth outcomes.
Offering doulas as part of a menu of choices in the prenatal period would be a way to empower women to be actively involved in preparing for birth and developing self-efficacy in maternal health behaviors.
Women offered evidenced-based health information, support in improving their prenatal health behaviors, and the kinds of support provided by doulas are likely to make more informed choices throughout the pregnancy regarding their health and that of their baby. The results of this study indicate that if offered a comprehensive system of psychosocial and health support, socially disadvantaged women can improve their birth outcomes.
The women served by this project often do not believe they can impact their health or their birth outcomes. Practitioners who work with them also often have little confidence that they can help disadvantaged women change their health behaviors and improve their birth outcomes. This study indicates that both of these groups can build their self-efficacy and together, as partners in this journey, improve birth outcomes.
Based on the empowerment model, both the mothers and the practitioners need to be copilots in improving health behaviors. Doulas, as part of a comprehensive system of support, can help mediate this process. Future research should attempt to isolate the variables that resulted in positive outcomes in this case. Questions to be examined include individual compared to group care with doula assistance, the optimal time for doula involvement, the role of informed decision making in birth outcomes, and perceptions and decision-making processes of women in opting for the support of a doula.
Hospital and community health policy may benefit from enhanced prenatal health and childbirth education and support including doula assistance for all women but particularly for women at risk for adverse birth outcomes because of homelessness, racial disparities, adolescence, violence, and lack of psychosocial support.
This support empowers women to take charge of their own prenatal health, thus improving birth outcomes. His research interests include adolescent pregnancy prevention and healthy birth outcomes. She has 13 years of experience at the YWCA of Greensboro developing and implementing programs for pregnant and parenting adolescents and young adult women at risk for adverse birth outcomes. National Center for Biotechnology Information , U. Journal List J Perinat Educ v. This article has been cited by other articles in PMC. Abstract Birth outcomes of two groups of socially disadvantaged mothers at risk for adverse birth outcomes, one receiving prebirth assistance from a certified doula and the other representing a sample of birthing mothers who elected to not work with a doula, were compared.
Assignment of Doulas to Expectant Mothers Expectant mothers who attended at least three of the eight childbirth classes were given the option to have a doula. Open in a separate window.
Impact Measures The impact of having a doula was assessed by the following measures: Comparative Analyses Proportions were compared using z -test analysis Joosse, RESULTS Type of Birth A summary of the number and percentages of the type of birth by whether the mother was an adolescent or adult and doula or nondoula assisted is presented in Table 2. Birth Complications The number of births involving a medical issue relating to either the mother or her baby is presented in Table 4. Initiation of Breastfeeding Initiation of breastfeeding percentages are presented in Table 5.
Limitations One limitation of this study is that participants self-selected themselves to work with a doula. Implications for Childbirth Educators and Nurses This study reinforces the case that doula involvement is a cost-effective method to improve outcomes for mothers and infants. Perceptions of social support from pregnant and parenting teens using community-based doulas.
Impact of Doulas on Healthy Birth Outcomes
A randomized control trial of continuous support in labor by a lay doula. Attitudes towards doula support during pregnancy by clients, doulas, and labor-and-delivery nurses: A case study from Tampa, Florida. Human Organization , 67 4 , — Gilliland A. The modern role of the professional doula.
Hispanic labor friends initiative: Group prenatal care and perinatal outcomes—a randomized controlled trial. Maternal nutrition and infant mortality in the context of relationality. Social support by doulas during labor and the early postpartum period. Hospital Physician , 37 9 , 57—65 Mottl-Santiago J.
HISTORY OF CHILDBIRTH IN AMERICA
A hospital-based doula program and childbirth outcomes in an urban, multicultural setting. Factors associated with exclusive breastfeeding among Latina women giving birth at an inner-city baby friendly hospital. Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae.
Doula support and attitudes of interpartum nurses: Supporting women in labor: Analysis of different types of caregivers. The first national U. Effects of labor support on mothers, babies, and birth outcomes. Birth , 28 1 , 52—56 [ PubMed ] Vonderheid S. Group prenatal care and doula care for pregnant women In Handler A.
The evidence from population-based interventions pp. Because friends and family were not allowed to visit, bed confinement further isolated the mother from any potentially supportive individuals. Childbirth interventions are currently at an all-time high. An inexperienced partner or family member of the woman may assist the nurse in support techniques. Due to the high incidence of short staffing, endless amount of charting, and continuous monitoring required by the nurses, little time is left for tending to the mother's emotional, spiritual, and physical needs. This, combined with many mothers' concern over the high rate of interventions, has resulted in some women choosing to give birth with the assistance of a professional support person or doula.
A doula is defined by Doulas of North America DONA as a woman who is trained and experienced in childbirth and provides continuous physical, emotional, and informational support to a woman during labor, birth, and the immediate postpartum period. Women choose to labor and give birth with doula support for a wide range of needs, goals, and concerns about their childbirth experience. Many women want to be encouraged and supported as they give birth without pain medications, while other women desire a liaison between themselves and the medical staff.
Doulas gained popularity during the s when women became distressed at the ever-increasing rate of cesarean sections. Women began to invite a female friend, their childbirth instructor, or an obstetrical nurse with whom they were friends to provide labor support in order to have an advocate to help them avoid routine procedures that could lead to a cesarean Gilliland, Although a primary goal of today's doulas remains helping women avoid unnecessary cesareans, their scope of practice is much broader.
The role of a doula is to provide specific labor-support skills, techniques, and strategies, offer guidance and encouragement, build a team relationship with the nursing staff, encourage communication between the patient and medical caregivers, and assist the mother in covering the gaps in her care. According to DONA n. Doulas use techniques such as imagery, massage, acupressure, and patterned breathing to reduce a woman's pain.
They suggest position changes to accelerate labor or aid in fetal positioning. They also provide guidance and encouragement to minimize fear and anxiety, and encourage touch and communication between the laboring woman and her partner. The nurse's role involves clinical skills and administrative responsibilities that are not part of the doula's role. She is responsible for assessing both the mother and baby, administering drugs and intravenous fluids, and stabilizing the newborn. This gap in care clearly provides a place in which doulas can assist in providing optimal intrapartum care.
Conflict between the doula and nurse is highly undesirable. The tension that could arise can have harmful emotional and physical effects for the laboring mother and fetus. Anxiety during labor leads to an endogenous release of catecholamines, which lowers uterine contractility and decreases placental blood flow. Therefore, it is imperative that the doula and the nurse work together and accept each other's roles. In , Bowers conducted a massive meta-analysis to review mothers' perceptions of labor support. Her review spanned 17 studies in a wide variety of birth settings with intrapartum support provided by midwives, nurses, or doulas.
Supportive actions were characterized according to the four dimensions of professional labor support: Perceptions of emotional support included the caregiver being friendly, open, and gentle, communicating a warm, positive regard for the laboring woman, and conveying a sense of security and well being. Constant presence was also an important aspect of emotional support. Nurses who were perceived as the most caring demonstrated genuine concern for the woman and her partner.
Personalized information from the nurse was important during all stages of labor, especially prior to the performance of procedures. Advocacy also played a role in women's perception of labor support. Women wanted to know their options and have their decisions respected. Understanding the actions that birthing women have reported as important to them can direct the practice of those who provide intrapartum care and serve as a guide for future research. Other studies have also demonstrated the benefits of continuous labor support.
The study focused on nulliparous women with whom a doula stayed during the entire labor. The doula provided touch, encouragement, information, and an explanation of hospital procedures. The study showed that continuous support by a doula significantly reduced the rate of cesarean section and forceps delivery, decreased oxytocin augmentation, and shortened the duration of labor.
In a meta-analysis of the effects of labor support on mothers, women who had continuous labor support had lower rates of analgesia and anesthesia use, lower operative birth rates, shorter labors, fewer newborns with 5-minute Apgar scores less than 7, and increased maternal satisfaction with the birthing process Sauls, Some data within the analysis also indicated women with doula support had more maternal-infant bonding, felt less anxious about motherhood, and had a lower incidence of postpartum depression.
Sauls's study spanned more than 30 published reports, reviews, commentaries, and randomized clinical trials in five countries, including the United States, Guatemala, South Africa, Canada, and Mexico. Although most of the reviewed studies had limitations, all found evidence of the beneficial effects of labor support. The most powerful of these effects occurred when birth companions other than nurses provided support.
A study by Hodnett examined pain and women's satisfaction with the experience of childbirth. Surprisingly, the researcher found that the amount of pain a woman experienced during childbirth factored little into her perception of her overall birth experience. However, in every instance, the quality of the relationship with and support from caregivers was a strong predictor of childbirth satisfaction. Several studies have also suggested that a support person, other than the intrapartum nurse, may be the best provider of supportive care.
Rosen performed a meta-analysis of eight randomized trials in which support provided by different types of caregivers was analyzed. These trials investigated untrained lay women, trained lay women, female relatives, nurses, lay midwives, and student lay midwives as support persons. The researcher found that continuous support by untrained lay women starting in early labor and continuing into the postpartum period demonstrates the most consistent, beneficial effect on childbirth outcomes.
In the Listening to Mothers survey, researchers polled 1, women who had given birth in the previous 24 months Sakala et al. A unique, yet significant role for doulas was examined by Pascali-Bonaro in Her study examined the impact of stress and grief on pregnant widows of the September 11, , attacks on the World Trade Center in New York City. Pascali-Bonaro's collaborative, interspecialty volunteer program extended for nine months after the attacks, providing free support and counseling by doulas and childbirth educators.
Her study demonstrates how doulas can help anxious mothers through childbirth by creating safe, comforting environments, encouraging women to design a birth plan that includes ways to make them feel secure during labor and birth before any catastrophic event may occur, and facilitating positive communication between the provider and client. Such data can likely extend to the general childbearing population who, inevitably, also experience at least some degree of tension and anxiety.
Although dozens of studies herald the benefits of continuous labor support and several more studies indicate that a doula may be the best provider of that continuous support, the relationship between doulas and intrapartum nurses has yet to be examined. However, in , Hazle did examine the relationship between nurse-midwives and intrapartum nurses. Her study included nurse-midwives and obstetric nurses. Each group received mailed questionnaires containing five sections: An analysis of the data compared activities perceived as appropriate to the nurse-midwife by both groups, in addition to attitudes and values held by each group and perceptions of the nurse-midwife's role definition and role conflict themes as reported through the critical incident report.
Data indicated that, although both groups basically held positive views of one another, inter-role conflict was present to some degree. Some issues of contention included support of breastfeeding and rooming-in, as well as support of women choosing prepared childbirth. In order to provide the best care possible to the laboring woman, it is essential that the doula and nurse accept and respect each other's unique roles. For them to accomplish this, each must identify any negative feeling they may harbor toward one another.
The purpose of the current pilot study was to examine the level of acceptance shown by the intrapartum nurse for doula support. The focus of the study was the mother's perception of this level of acceptance because the nurse and doula's relationship will impact her comfort with her total care during labor. Consequently, the following clinical question was examined: To what level do intrapartum nurses accept doula support, as perceived by the patient? Because little to no research explores the relationship between doulas and intrapartum nurses, a qualitative approach was used.
This study was conducted involving English-speaking women who gave birth to a healthy infant with the assistance of a professional doula in a hospital in north central Alabama. Women whose doulas were family members were excluded, as were any women whose infants were born with a major medical condition. Women who had utilized the services of a doula were contacted by that doula and asked to call or email the researcher if they were interested in participating in the study.
The researchers obtained approval from the university's institutional review board and informed consent from participants. Questionnaires were sent and returned via email. The questions were approved by a panel of experts that included a doctorally prepared nurse educator with experience in research and obstetrics, a certified nurse-midwife with over 20 years of experience working with nurses and doulas, a registered nurse with six years of experience in labor and birth, and a certified doula and childbirth educator.
Interview questions were as follows:. To establish inter-rater reliability, themes were identified by the investigators and reviewed for validity by a panel of experienced researchers, including a baccalaureate-prepared registered nurse, a doctoral level research student, and a nursing educator.
Eleven questionnaires were emailed to participants who expressed interest in participating in the study. Nine questionnaires were completed and returned. Participants were all Caucasian women ranging in age from 21 to 40 years, with a mean age of All participants gave birth vaginally. Five of the eight women were primiparas, and four were multiparas. The study participants were asked about the support provided by their doula and by their intrapartum nurse. The results were arranged in subcategories of physical and psychosocial see Table 1.
In this study, levels of acceptance toward doula support offered by intrapartum nurses were divided into two themes:.
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Participants' perceptions of the nurse's attitude toward the support provided by their doula is outlined in Table 2. Women reported that these conflicts had a negative impact on their birth experience. When participants were asked for recommendations for nurses and doulas working together, all advice was directed toward nurses and other medical staff. Direct quotes from participants are outlined in Table 3. Resentment and animosity detected in the nurse's attitude could potentially be attributed to an intrusive or hostile attitude from the doula. However, in this small study, that did not seem to be the case.
The current study raises questions that will be useful in a follow-up study. The dichotomy suggested by this study indicates that, while some intrapartum nurses are perceived to view the doula's role as positive and one that may even facilitate their own responsibilities, others are perceived as viewing the doula's role in negative terms. The reason some nurses are not accepting of doula support cannot be fully understood without further research. Do nurses feel their role is threatened by the presence of a doula? Do they believe the presence of a doula hinders a safe labor and birth? Are they so accustomed to a medicalized birth that they are unable or unwilling to adapt to an alternative support person?
These nurses may possibly be unaware that the patient perceives their attitudes as negative. It is also possible that the presence of a doula factors little into their resentful attitude. Perhaps these nurses were just having a bad day or the unit was understaffed, or they would be viewed as having a negative attitude even in the absence of a doula.
These are all questions that must be answered with future studies. Nurses themselves should be interviewed to investigate how they feel about doula support. Doulas should also be interviewed to see if their perception of nurses' attitudes coincides with that of the patient. Further research should also examine if the nurse is resentful because of the presence of a doula or because the mother chose to give birth naturally, without many of the medical interventions provided to most patients.
Limitations in this study include an all-Caucasian population and a regional bias. In future research, doula support of Hispanic, Asian, or African-American women must be examined. Would nurses be more or less likely to accept doula support if it were viewed from a cultural perspective? Because this study was conducted in the Southeast, little is known about how nurses from other parts of the United States view doula support.
Related Experienced Doula: Advanced Skills for Hospital Doulas
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