After praise and encouragement: emotional support strategies used by birth doulas in the USA and Canada

The role of doulas in supporting perinatal mental health - a qualitative study

Objective

The perinatal period presents several opportunities to identify and treat perinatal mental health and substance use disorders by integrating into existing care pathways. We aimed to examine the role of birth doulas in supporting their clients' perinatal mental health.

Methods

Thematic content analysis of focus groups with doulas, and interviews with doula clients was used to characterize the doula-client relationship, investigate whether and how doulas provide mental health and substance use support, and identify barriers and recommendations for doulas to support their clients' mental health. Participants were doula clients from communities underserved due to race, income, language and culture.

Results

Doulas and clients reported positive relationships, supported by congruence in culture, language, and lived experiences. Doulas varied in their confidence in identifying perinatal mental health problems, though most agreed that doulas could support their clients' mental health to different degrees. Barriers to engaging in perinatal mental health treatments included low perceived need and socio-economic burden.

Conclusions

With adequate support and training, doulas can play an important role in supporting their client's emotional well-being.

Community-Based Doulas' Roles Within the Birth Support System: Young Black Mothers' Perspectives

INTRODUCTION

Doulas have been found to be beneficial to pregnant adolescents during childbirth, but little is known about their role within the larger system of people providing birth support, including family and health care providers. The purpose of this study was to examine, from the perspectives of young mothers, the role of the doula within their broader birth support system.

METHODS

One hundred pregnant Black adolescents and young women (aged 13 to 21) who were provided perinatal community-based and racially concordant doula services at no cost to them were interviewed after the birth of their newborn, prior to hospital discharge. Interviews generated birth story narratives and responses to focused questions about their experiences of birth support. Thematic analysis was conducted to examine the role of the doula within the context of the broader system of birth support.

RESULTS

Doulas functioned in 2 primary ways within the birth support system by (1) providing tandem support alongside family and health care providers and (2) filling gaps in health care not provided by family and providers. Laboring adolescents sometimes described their family members and doulas working in tandem to provide multiple types of support such as comfort measures, coaching, and help with pushing. They also identified gaps in their care or support filled by the doula, in particular gaps due to family members' physical or emotional unavailability or health care providers' many responsibilities.

DISCUSSION

The findings highlight the ways in which doulas support pregnant adolescents during childbirth through their deft navigation of the existing support system. Well-being was enhanced by the inclusion of the doula in the birth support system. The findings align with existing research that underscores the valuable role doulas play in supporting individuals during childbirth, particularly for those most affected by processes of marginalization.

'Do we need doulas…?' - Perspectives of maternity care managers on the role of doulas in Poland

AIM

The purpose of this study was to analyse perinatal care managers' perspectives on the role of doulas in Poland and to consider how managers' perspectives might affect the opportunities for doulas to practice in individual hospitals.

DESIGN

This is a qualitative descriptive study.

METHOD

The total of 17 hospitals was selected for the study. Semi-structured interviews were conducted with 11 manager staff members.

RESULTS

Three groups of facilities were identified: '0' (n = 6) - refused to give interviews, 'A' (n = 8) - marginal experience in working with doulas, and 'B' (n = 3) - regular experience in working with doulas. The hospitals from Group A showed indifference towards working with doulas. Group B declared a positive attitude towards such cooperation. Attitudes towards doulas vary among executives and are related to the frequency of doula-assisted births. Our results indicate factors that may influence the attitude of medical staff towards doulas and which may contribute to improve future initiatives meant to facilitate collaboration between midwives and doulas.

PATIENT OR PUBLIC CONTRIBUTION

This study explored the lived experiences of perinatal care managers.

Providing Emotional Support and Physical Comfort During a Time of Social Distancing: A Thematic Analysis of Doulas' Experiences During the Coronavirus Pandemic

Doulas are trained, non-clinical professionals that provide a continuum of support for mothers. An interpretive phenomenological approach was used to explore the professional experiences of doulas (n = 17) during the COVID-19 pandemic in the US. Data were collected using brief intake surveys, in-depth semi-structured interviews, and an online discussion group. After a list of significant statements was created and grouped during emergent themes analysis, the reflections were summarized into three themes, (1) Doula Resilience, (2) Experiencing Vulnerability, and (3) Concern for Client Vulnerability that encapsulate the experiences of doulas during the COVID-19 pandemic. We conclude that as part of the COVID-19 recovery process, policy makers should look to non-clinical interventions for improving maternal health, such as promoting and supporting synergy between doulas and other maternal health service providers.

Cooperation between midwives and doulas in the context of perinatal care - a integrative review of qualitative and quantitative studies

BACKGROUND

A doula is a person who provides support to women in the perinatal period without providing medical services. During childbirth, the doula becomes a member of the interdisciplinary team. This integrative review aims to analyse the nature of the cooperation between doulas and midwives, its efficiency and challenges and ways of strengthening this cooperation.

METHODS

A structured integrative review of empirical and theoretical studies written in English was conducted. The literature search included MEDLINE, Cochrane, Scopus, ProQuest, Science Direct, Web of Science, and Embase Health Source: Nursing/Academic Edition databases. The analysis included papers published in 1995-2020. Dedicated documents were searched for different combinations of terms and standard logical operators. A manual search of the studies was included for additional references.

RESULTS

Twenty-three articles from 75 full-text records were analysed. Three main themes emerged. (1) doulas are needed to prop up the system (2) barriers in collaboration between midwives and doulas; and (3) how cooperation between midwives and doulas can be strengthened. None of the articles referred directly to the impact of collaboration between midwives and doulas on the quality of perinatal care.

CONCLUSION

This is the first review to analyse the impact of collaboration between midwives and doulas on the quality of perinatal care. Ensuring adequate collaboration between doulas and midwives requires effort from both of these professional groups and the health care system. However, such collaboration is supportive for birthing women and the perinatal care system. Further research in terms of the impact of this collaboration on the quality of perinatal care is needed.

Doula Support Challenges and Coping Strategies during the COVID-19 Pandemic: Implications for Maternal Health Inequities

The COVID-19 pandemic has made birthing more stressful and isolating, which has raised particular concern for populations of birthing people affected by maternal health inequities. Doulas have been proposed as one means of improving health outcomes by providing emotional, physical, and informational support to patients and their families before, during, or after labor. However, the social and economic conditions of the COVID-19 pandemic have posed new challenges for doula care. We conducted thematic analysis on 25 semi-structured interviews with practicing doulas in the United States to explore changes to doula care during the pandemic. Although doulas have faced many challenges in providing virtual and socially-distanced support during the pandemic, the rising use of telehealth among doulas has revealed new coping strategies and opportunities for virtual communication with the doula community. Our findings indicate that doula experiences during the pandemic can inform future doula care practices, particularly for birthing people of color and low-income birthing people.

Doula Support Challenges and Coping Strategies during the COVID-19 Pandemic: Implications for Maternal Health Inequities

The COVID-19 pandemic has made birthing more stressful and isolating, which has raised particular concern for populations of birthing people affected by maternal health inequities. Doulas have been proposed as one means of improving health outcomes by providing emotional, physical, and informational support to patients and their families before, during, or after labor. However, the social and economic conditions of the COVID-19 pandemic have posed new challenges for doula care. We conducted thematic analysis on 25 semi-structured interviews with practicing doulas in the United States to explore changes to doula care during the pandemic. Although doulas have faced many challenges in providing virtual and socially-distanced support during the pandemic, the rising use of telehealth among doulas has revealed new coping strategies and opportunities for virtual communication with the doula community. Our findings indicate that doula experiences during the pandemic can inform future doula care practices, particularly for birthing people of color and low-income birthing people.

Fading into the woodwork: Doula work and hospital-based practice

Doulas offer emotional support to women during pregnancy, childbirth, and the early postpartum period. In hospitals, doulas support their clients without holding formal status as employees or as a regulated profession. Drawing on interviews with 26 doulas in Toronto, Canada, along with analyses of the legacy of medical dominance in maternity care, I examine how doulas accomplish their work in hospitals. I find that doulas face challenges accessing physical resources and struggle to provide their model of care in light of routine hospital procedures and interventions. In response, many doulas develop strategies to address the constraints imposed by their work contexts. These findings suggest that the medical model of birth is resistant to even minor modifications or perspectives that view birth holistically rather than solely dependent on medical intervention.

The effect of backup midwife on maternal experience after vaginal childbirth - a qualitative study

One of the goals of reproductive health enhancement is to ensure the desired experience of safe childbirth by reducing possible complications, fears, and worries about delivery by ongoing midwife backup care. This study explains women's experiences with a backup midwife during labor and childbirth. This was a qualitative study involving 19 women who had natural childbirth in Hamadan, 2020. Purposeful sampling and data collection were performed using semi-structured in-depth interviews. Data were analyzed by conventional content analysis using MAXQDA software version 10. Data analysis showed three themes and six main categories. The themes included security, high-quality care, and respectful care, consisting of two main categories of perceived empowerment and support, physiological approach and reassuring care, and respect for the mother's privacy and optimal accountability. The presence of a backup midwife during labor caused a sense of security, control, and perceived empowerment, thus a positive childbirth experience. Therefore, it is necessary to train and employ midwifery in the healthcare system. It is recommended to train and employ midwifery graduates for this purpose and include it as one of the basic principles in the current planning to promote natural childbirth.

A pilot study of trained ICU doulas providing early psychological support to critically ill patients

Background

Over a third of critical illness survivors suffer from mental health problems following hospitalization. Memories of delusional experiences are a major risk factor. In this project, ICU doulas delivered a unique positive suggestion intervention targeting the vulnerable time period during critical illness when these memories are formed.

Methods

Adult critically ill patients were recruited for this single-arm, prospective pilot study. These ICU patients received a positive suggestion intervention daily during their ICU stay in parallel with their medical treatment. The intervention was designed to be delivered over a minimum of two sessions. Feasibility was defined as intervention delivery on ≥ 70% of ICU days after patient enrollment. As a secondary analysis, psychometric questionnaires were compared to those of a historic control cohort of patients receiving standard care in the ICU using adjusted linear regression models.

Results

Of the 97 patients who received the intervention and were alive at the end of their ICU course, 54 were excluded from analyses mostly for having received only one session because of a short ICU length of stay of < 2 days, transitioning to comfort care or not wanting to answer the study questionnaires. Forty-three patients who completed 2 or more sessions of the positive therapeutic suggestion intervention provided by two trained ICU doulas received it for a median of 4 days (IQR 3, 5), with each session lasting for a median of 20 min (IQR 14, 25). The intervention was delivered on 71% of days, meeting our pre-determined feasibility goal. Compared to historical controls (N = 299), patients receiving the intervention had higher severity of illness and longer length of stay. When adjusted for baseline differences, patients both with and without mechanical ventilation who received the intervention scored lower on the Hospital Anxiety and Depression Scale (HADS)—Depression subscale. The intervention was also associated with reduced HADS-Anxiety subscale among ventilated patients.

Conclusions

Positive therapeutic suggestion delivered by ICU doulas is feasible in the ICU setting. A randomized trial is warranted to better delineate the role that positive suggestion and ICU doulas may play in ongoing interprofessional efforts to humanize critical care medicine.

The study was registered on clinicaltrials.gov (NCT03736954) on 03/14/2018 prior to the first patient enrollment https://clinicaltrials.gov/ct2/show/NCT03736954?cond=ICU+Doulas+Providing+Psychological+Support&draw=2&rank=1.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03856-3.

Community Perspectives on the Creation of a Hospital-Based Doula Program

Objective: Racial and ethnic inequities in perinatal health outcomes are pervasive. Doula support is an evidence-based practice for improving maternal outcomes. However, women in lower-income populations often do not have access to doulas. This study explored community perspectives on doula care to inform the development of a hospital-based doula program to serve primarily low-income women of color.

Methods: Four focus groups and four individual interviews were conducted with: (1) women who were pregnant or parenting a child under age 2 (n=20); (2) people who had provided support during a birth in the previous 2 years (n=5); and (3) women who had received doula training (n=4).

Results: Participants had generally positive perceptions of doula services. Many aspects of doula support desired by participants are core to birth doula services. Participants identified ways that doulas could potentially address critical gaps in health care services known to impact outcomes (e.g., continuity of care and advocacy), and provide much-needed support in the postpartum period. Responses also suggested that doula training and hospital-based doula programs may need to be adapted to address population-specific needs (e.g., women with substance use disorder and younger mothers). Novel program suggestions included “on call” informational doulas.

Conclusions: Findings suggested that women in racial/ethnic minority and lower income groups may be likely to utilize a hospital-based doula program and identified adaptations to traditional doula care that may be required to best meet the needs of women in groups with higher risk of poor maternal health and birth outcomes.

Accompanying the Path of Maternity: The Life History of a Colombian Doula

Doulas have fundamentally improved the health-care experience of pregnant women internationally. Women who recognize the importance of not being alone during pregnancy have embraced this role for centuries. However, less is known about doulas practicing in countries experiencing health inequities like Colombia. Miller's methodology and Atkinson's interview domain was used to answer the question “What life experiences led a Colombian woman to become a doula?” A central theme emerged, “A calling from within: Growing up to accompany the transition from woman to mother.” The path to becoming a doula evolved from life experiences involving health inequities, and a sense of femininity, maternity, and the women's role in rural Colombia.

System of Psychological Support Based on Positive Suggestions to the Critically Ill Using ICU Doulas

Background:

Surviving critical illness often creates a lasting psychological impact, including depression, anxiety, and post-traumatic stress. Memories of frightening and delusional experiences are the largest potentially modifiable risk factor, but currently, there is no proven intervention to improve these inciting factors. Psychological support based on positive suggestion is a psychotherapeutic approach that can be provided even to patients in altered cognitive states and is therefore a viable psychotherapy intervention throughout the ICU stay. Traditional ICU care team members have limited time and training to provide such psychological support to patients. Doulas are trained supportive companions who have been effectively used to provide patient advocacy and emotional support in other clinical settings and may address this need. Our aim was to train and implement a psychological support based on positive suggestion program for the critically ill using doulas, and measure acceptance of this intervention through stakeholder feedback.

Methods:

Doula training included three objectives: an introduction to ICU practice structure and policies; education about fundamental aspects of critical care conditions and procedures; and didactic and hands-on learning experiences in effective use of psychological support based on positive suggestion in the critically ill. Doulas were evaluated at the end of their training and during subsequent clinical activities using competency-based assessments as well as through survey-based questions and interviews with key stakeholders.

Results:

The ICU doulas performed psychological support based on positive suggestion on 43 critically ill patients in the ICU setting. Stakeholder feedback from nurses, patients, and patient families was positive. The majority (28/32) of surveyed bedside ICU nurses reported that the doulas’ involvement was helpful for both patients and nurses alike. All interviewed family members offered positive comments about the ICU doula presence and of the 40 patients who recalled the intervention 37 found it comforting.

Conclusions:

Our program successfully trained two doulas to work effectively in the ICU setting performing patient-centered psychological support based on positive suggestion interventions. Their training improved their skill sets and was reported as beneficial by patients, families, and critical care nursing. This training program offers a proof of concept that could be applied in other medical centers, bringing doulas more commonly into the ICU practice to help humanize the experience for patients, families, and medical teams.

Perceptions and experiences of labour companionship: a qualitative evidence synthesis

BACKGROUND

Labour companionship refers to support provided to a woman during labour and childbirth, and may be provided by a partner, family member, friend, doula or healthcare professional. A Cochrane systematic review of interventions by Bohren and colleagues, concluded that having a labour companion improves outcomes for women and babies. The presence of a labour companion is therefore regarded as an important aspect of improving quality of care during labour and childbirth; however implementation of the intervention is not universal. Implementation of labour companionship may be hampered by limited understanding of factors affecting successful implementation across contexts.

OBJECTIVES

The objectives of the review were to describe and explore the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders regarding labour companionship; to identify factors affecting successful implementation and sustainability of labour companionship; and to explore how the findings of this review can enhance understanding of the related Cochrane systematic review of interventions.

SEARCH METHODS

We searched MEDLINE, CINAHL, and POPLINE K4Health databases for eligible studies from inception to 9 September 2018. There were no language, date or geographic restrictions.

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; focused on women's, partners', family members', doulas', providers', or other relevant stakeholders' perceptions and experiences of labour companionship; and were from any type of health facility in any setting globally.

DATA COLLECTION AND ANALYSIS

We used a thematic analysis approach for data extraction and synthesis, and assessed the confidence in the findings using the GRADE-CERQual approach. We used two approaches to integrate qualitative findings with the intervention review findings. We used a logic model to theorise links between elements of the intervention and health and well-being outcomes. We also used a matrix model to compare features of labour companionship identified as important in the qualitative evidence synthesis with the interventions included in the intervention review.

MAIN RESULTS

We found 51 studies (52 papers), mostly from high-income countries and mostly describing women's perspectives. We assessed our level of confidence in each finding using the GRADE-CERQual approach. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this.Labour companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating non-pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (low confidence). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision-making.Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign-born women in high-income settings may appreciate support from community-based doulas to receive culturally-competent care (low confidence).Factors affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).We compared our findings from this synthesis to the companionship programmes/approaches assessed in Bohren's review of effectiveness. We found that most of these programmes did not appear to address these key features of labour companionship.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several of these review findings. Further research, especially in low- and middle-income settings and with different cadres of healthcare providers, could strengthen the evidence for low- or very low-confidence findings. Ahead of implementation of labour companionship, researchers and programmers should consider factors that may affect implementation, including training content and timing for providers, women and companions; physical structure of the labour ward; specifying clear roles for companions and providers; integration of companions; and measuring the impact of companionship on women's experiences of care. Implementation research or studies conducted on labour companionship should include a qualitative component to evaluate the process and context of implementation, in order to better interpret results and share findings across contexts.

Skilled health attendants' knowledge and practice of pain management during labour in health care facilities in Ibadan, Nigeria

INTRODUCTION

Skilled health attendants occupy an important position in the management of women's pain during labour. Their professional goal is to ensure safety and minimum pain in labour. It has been revealed that nurse-midwives are deficient in knowledge and practice of pain management during labour. Hence, this study examined skilled health attendants' knowledge and practice of pain management in health care facilities in Ibadan, Nigeria.

METHODS

A cross-sectional design was used to collect data from 227 skilled health attendants, in the maternity units of the three purposively selected hospitals for 12 weeks. A structured questionnaire and observational check lists were used for data collection. Data were analyzed using descriptive statistics and significants level was set with p<0.05.

RESULTS

Results on respondents' level of knowledge revealed that 6% had low knowledge, 40.5% moderate, and 56.8% had a high level. The majority, 79.7%, were registered nurse-midwives (RN/RM) and 90.1% employed reassurance for pain relief. No significant associations were found between respondents' level of education and reassurance, exercise, allay of fear, use of drugs, and TENS (p>0.05). However, there were significant associations between respondents' educational level and rubbing of back/massage, position change, cold/warm bath, relaxation, and social support (p<0.05).

CONCLUSIONS

It is recommended that seminars and workshops should be organized regularly and assessment tools should be supplied, to enhance effective pain assessment as this will provide adequate and holistic labour-pain management by nurse-midwives.

Becoming a Voluntary Doula: Personal and Caring Motives

Background:

Voluntary doula care, as a complement to midwifery care, is emerging as support for women and their families throughout the childbearing period. Doula care is not an official part of the public health care system in Nordic countries.

Aim:

The aim was to describe and interpret women’s experiences of becoming voluntary unpaid doulas and to generate a model as part of a research program.

Method:

Latent qualitative content analysis was chosen using interviews with nine voluntary doulas in an NGO group in Finland.

Findings:

Becoming a voluntary doula seems to be related to two motives, personal and caring. Interest in and fascination with childbearing, doula care as rewarding and joyous but challenging work, and networking and affinity in the doula group are personal motives. The caring motives were seeing doula care as important for the childbearing woman and her partner, being humble about childbearing knowledge, understanding vulnerability and uniqueness in childbearing based on their own experiences, and seeing doula care as a complement to midwifery care.

Conclusion:

A model has been created suggesting that the balance between the two motives might be crucial for doula care. Ethical reflections on the motives for becoming and being a doula need to be supported in a caring culture where the primary focus is the best care for the woman and her partner in childbearing.

Challenges in implementing continuous support during childbirth in selected public hospitals in the North West Province of South Africa

Background

According to a Cochrane review, continuous support during childbirth increases the mother’s chances of a vaginal birth without identified adverse effects. However, this evidence-based practice is not universally implemented. The objective of the study was to identify challenges encountered in implementing continuous support during childbirth in public hospitals in the North West Province of South Africa.

Method

An explorative, descriptive and contextual qualitative approach was used. The data were collected during 2013 by conducting focus group interviews with 33 registered midwives who had worked in maternity units in three selected public hospitals in the North West Province for at least two years.

Results

Midwives identified challenges that negatively impacted the implementation of continuous support during childbirth at organisational and interpersonal levels. At the organisational level, challenges included human resources, policies and guidelines as well as the architectural outlay of the maternity units. The personal challenges related to communication and attitudes of nurses, patients and their families.

Conclusions

Organisational and personal challenges had a negative impact on the provision of continuous care during childbirth.

Experiences of midwives on pharmacological and non-pharmacological labour pain management in Ghana

BACKGROUND

Due to the debilitating effects of severe labour pains, labour pain management continues to be an important subject that requires much attention. Thus, this study sought to gain a detailed insight into the experiences of midwives on pharmacological and non-pharmacological labour pain management strategies in a resource limited clinical context.

METHODS

A descriptive exploratory qualitative design was adopted for this study which allowed in-depth follow-up of the midwives' comments resulting in a full understanding of emerging findings. Face-to-face individual interviews were conducted, transcribed and data were analysed using content analysis procedures. Verbatim quotes were used to support the findings.

RESULTS

Midwives employed different pain control measures including pharmacological and non-pharmacological methods such as psychological care, sacral massage and deep breathing exercises. Doctors prescribed analgesics most of the time while in some cases, the midwives independently administered the drugs. They assisted women who had epidural anaesthesia given by anaesthetists. The midwives did not administer adequate analgesics because of fear of side effects of analgesics. Although the midwives exhibited knowledge on drugs used for labour pain management, they did not regularly administer analgesics and non-pharmacological care provided were inadequate due to increased workload. Some of the midwives showed empathy towards women and supported the women. Most of the midwives perceived labour pain as normal and encouraged women to bear pain.

CONCLUSION

Midwives require regular education on labour pain management and they should pay attention to women in labour individually and administer the care that meets their need.

A qualitative study of volunteer doulas working alongside midwives at births in England: Mothers' and doulas' experiences

OBJECTIVE

to explore trained volunteer doulas' and mothers' experiences of doula support at birth and their perceptions of how this related to the midwife's role.

DESIGN

a qualitative descriptive study, informed by phenomenological social psychology.

METHODS

semi-structured interviews were carried out between June 2015 and March 2016. Interview transcripts were analysed using inductive thematic analysis.

SETTING

three community volunteer doula projects run by third sector organisations in England.

PARTICIPANTS

19 volunteer doulas and 16 mothers who had received doula support during labour.

FINDINGS

three overarching themes emerged: (1) 'the doula as complementary to midwives', containing subthemes 'skilled physical and emotional support', 'continuous presence', 'woman-centred support', 'ensuring mothers understand and are understood' and 'creating a team for the mother'; (2)'the doula as a colleague to midwives', containing subthemes 'welcomed as a partner', 'co-opted to help the midwives', and 'doulas identify with the midwives'; and (3) 'the doula as challenge to midwives', containing subthemes 'confusion about the doula's role', 'defending informed choice', and 'counterbalancing disempowering treatment'. KEY CONCLUSIONS&IMPLICATIONS FOR PRACTICE: volunteer doulas can play an important role in improving women's birth experiences by offering continuous, empowering, woman-focused support that complements the role of midwives, particularly where the mothers are disadvantaged. Greater clarity is needed about the scope of legitimate volunteer doula advocacy on behalf of their clients, to maximise effective working relationships between midwives and doulas.

Comparison of the Effects of Using Physiological Methods and Accompanying a Doula in Deliveries on Nulliparous Women's Anxiety and Pain: A Case Study in Iran

Childbirth is a great moment in a woman's life and is inevitably influenced by emotional, social, and psychological stress. This study aimed to assess the anxiety and pain level of nulliparous women giving birth using physiological methods (without doula support) during labor and those women supported by a doula at Towhid Hospital of Jam, Bushehr, Iran in 2015. In this interventional study, 150 women were randomly assigned to either an intervention (with doula support) or a control group (with no doula support). The intrapartum, postpartum, and hidden anxiety levels were measured using Spielberger standard questionnaire used for assessing anxiety. The labor pain rate was evaluated using McGill questionnaire. Results showed that the average rate of obvious anxiety during labor was 57.76 ± 9.57 in physiological delivery (without doula) and 48.04 ± 9.61 in doula-supported delivery. The difference between mean scores of obvious anxiety during labor was significant. The mean anxiety of the control group (who did not receive doula support) was higher (P = .000). Also, the difference between the mean labor pain scores of the 2 groups was statistically significant. The results of the study showed that doula's presence has positive significant effects on labor pain and anxiety reduction; also, doula-supported mothers reported considerably lower pain and anxiety compared with those experiencing physiological delivery (without doula). Thus, the increased use of doula in hospitals all over the country is recommended.

North American Nurses' and Doulas' Views of Each Other

OBJECTIVE

To analyze factors that lead nurses and doulas to have positive views of each other.

DESIGN

A multivariate analysis of a cross-sectional survey, the Maternity Support Survey.

SETTING

Online survey with labor and delivery nurses, doulas, and childbirth educators in the United States and Canada.

PARTICIPANTS

A convenience sample of 704 labor and delivery nurses and 1,470 doulas.

METHODS

Multiple regression analysis was used to examine five sets of hypotheses about nurses' and doulas' attitudes toward each other. Scales of nurses' attitudes toward doulas and doulas' attitudes toward nurses included beliefs that nurses/doulas enhance communication, are collaborative team members, enhance a woman's birth experience, interfere with the ability to provide care, or interfere with relationships with the women for whom they care.

RESULTS

For nurses, exposure to doulas in their primary hospitals was associated with more positive views, whereas working more hours, feeling overworked, and a preference for clinical tasks over labor support were associated with more negative views of doulas. For doulas, working primarily in one hospital and certification were associated with more positive views of nurses. Nurses with more positive attitudes toward common obstetric practices had more negative attitudes toward doulas, whereas doulas with more positive attitudes toward common obstetric practices had more positive attitudes toward nurses.

CONCLUSION

Our findings show factors that influence mutual understanding and appreciation of nurses and doulas for each other. These factors can be influenced by educational efforts to improve interprofessional collaboration between these maternity care support roles.

The Value of the Maternity Care Team in the Promotion of Physiologic Birth

The benefits of normal, physiologic birth have been well documented. Health care providers such as nurses, midwives, and physicians have distinct and significant roles in the promotion of physiologic birth processes. By supporting women and families, doulas can enhance the maternity care team and further facilitate physiologic birth. A collaborative maternity care team can foster and support a common goal of safe, satisfying, and affordable care practices associated with physiologic birth.

What Motivates People to Attend Birth Doula Trainings?

Eighteen identified motivations for attending a birth doula training workshop were ranked by 467 participants (466 females, 1 male) in 2010 and 2013. Participants selected a variety of reasons but only 30% chose to "become a professional doula" as their main reason. Another 20% wanted to "become a midwife." Remaining participants selected 16 other professional and personal motivations, such as "increase birth knowledge," "understand my own births," "make future births better," and "help women have better births (not as a professional)." One quarter had not attended a birth or had a child. Besides career training, these workshops are filling a cultural gap in childbirth education for people who are not expectant parents, and who intend to use this knowledge in unanticipated ways.

Comparison of the Effects of Maternal Supportive Care and Acupressure (at BL32 Acupoint) on Labor Length and Infant's Apgar Score

BACKGROUND & OBJECTIVES

Prolonged labor leads to increase of cesarean deliveries, reduction of fetal heart rate, and maternal as well as infantile complications. Therefore, many women tend to use pharmacological or non-pharmacological methods for reduction of labor length. The present study aimed to compare the effects of maternal supportive care and acupressure (at BL32 acupoint) on labor length and infant's Apgar score.

METHODS

In this clinical trial, 150 women with low-risk pregnancy were randomly divided into supportive care, acupressure, and control groups each containing 50 subjects. The data were collected using a questionnaire including demographic and pregnancy characteristics. Then, the data were analyzed using Chi-square test and one-way ANOVA.

RESULTS

The mean length of the first and second stages of labor was respectively 157.0±29.5 and 58.9±5.8 minutes in the supportive care group, 161.7±37.3 and 56.1±31.4 minutes in the acupressure group, ad 281.0±9.8 and 128.4±44.9 minutes in the control group. The difference between the length of labor stages was significant in the three study groups (P<0.001). Moreover, the frequency of Apgar score>8 in the first and 5th minutes was higher in the supportive care and acupressure groups compared to the control group, and the difference was statistically significant (P<0.001).

CONCLUSION

Continuous support and acupressure could reduce the length of labor stages and increase the infants' Apgar scores. Therefore, these methods, as effective non-pharmacological strategies, can be introduced to the medical staff to improve the delivery outcomes.

Trained or professional doulas in the support and care of pregnant and birthing women: a critical integrative review

The professionalisation of doula care and research interest in this area of maternity care/support have both grown internationally in recent years highlighting important broader issues around the access, continuity and delivery of maternity care services. However, no work to date has provided a critical appraisal of the international literature on this topic. In response, this paper presents the first critical review of international empirical literature examining professional doula care for pregnant and birthing women. A database search of AMED, CINAHL, Maternity and Infant Care, and MEDLINE using the search term, "doula" was undertaken. A total of 48 papers published between 1980 and March 2013 involving trained or professional doulas were extracted. Four descriptive categories were identified from the review: 'workforce and professional issues in doula care'; 'trained or professional doula's role and skill'; 'physical outcomes of trained or professional doula care'; and 'social outcomes of trained or professional doula care'. Of the studies evaluating outcomes of doula care, there were a number with design and methodology weaknesses. The review highlights a number of gaps in the research literature including a lack of research examining doula workforce issues; focus upon the experience and perspective of significant stakeholders such as expectant fathers with regard to trained or professional doula care; clinical trials measuring both subjective experiences and physical outcomes of trained or professional doula support; synergy between the design of clinical trials research examining trained or professional doula care and the clinical reality of professional doula practice. It is imperative that key aspects of trained doula care be subject to further rigorous, empirical investigation to help establish an evidence base to guide policy and practice relating to this area of support and care for pregnant and birthing women.

Emotional support for diabetes management: an international cross-cultural study

PURPOSE

The purpose of this study was to explore how emotional support emerged in interactions between peer supporters (PSs) and adults living with type 2 diabetes.

METHODS

Qualitative data were analyzed from 22 semistructured interviews with PSs in 3 settings: low-income Latinos in Chicago, middle-class Caucasians in the United Kingdom, and low-income African American women in North Carolina. Emotional support was defined as expressions of empathy, trust, and caring.

RESULTS

Across all sites, emotional support gradually emerged over time, was often combined with informational support, and was conveyed both implicitly (through nonverbal actions connoting emotional acceptance; eg, a walk together without discussion of problems) and explicitly (eg, by reassurance or discussion of stressors). Cross-site differences did appear regarding the strategies to address barriers to diabetes management (eg, PSs in North Carolina and Chicago reported providing support for social stressors) and the role of PSs (eg, PSs in Chicago reported providing directive support).

CONCLUSIONS

Across different settings and populations, emotional support for diabetes management evolved over time, was often integrated with informational support, and emerged through both implicit and explicit strategies that addressed varied context-specific stressors.

Defining the doula's role: fostering relational autonomy

BACKGROUND

Training organizations as well as academic and popular literature provide ambiguous or ethically contentious characterizations of the role of the birth doula, a non-clinical role assisting women in pregnancy and birth with information and physical and emotional support. Doulas have been criticized for attempting to impose their own agendas on their clients and for interfering with the relationship between women and their medical caregivers.

OBJECTIVE

To develop a theoretically grounded model of the birth doula's role to guide constructive practice and refute some training organizations' and doulas' adoption of an active 'advocacy' role with clients that can lead to inappropriate practices.

DESIGN

Apply the theoretical framework of relational autonomy to the components of the work that doulas perform with their clients.

DISCUSSION AND CONCLUSIONS

The conceptual framework of relational autonomy recognizes the social context in which women make choices about their care in pregnancy and birth, instead of assuming that autonomy is exercised in isolation. To support this understanding of autonomy, a relational model emphasizes women's skills development, self-confidence and recognition of the social context for decisions. Highlighting these aspects of exercising autonomy reduces the potential for the doula to seek to influence her client. The doula's role is reframed as one of facilitating patient engagement and shared decision-making.

Comparison of the effects of maternal supportive care and acupressure (BL32 acupoint) on pregnant women's pain intensity and delivery outcome

Delivery is considered as one of the most painful experiences of women's life. The present study aimed to compare the effects of supportive care and acupressure on the pregnant women's pain intensity and delivery outcome. In this experimental study, 150 pregnant women were randomly divided into supportive care, acupressure, and control groups. The intensity of pain was measured using Visual Analogue Scale (VAS). The supportive care group received both physical and emotional cares. In the acupressure group, on the other hand, BL32 acupoint was pressed during the contractions. Then, the data were analyzed using descriptive and inferential statistics. The results revealed significant difference among the three groups regarding the intensity of pain after the intervention (P < 0.001). Besides, the highest rate of natural vaginal delivery was observed in the supportive care group (94%) and the acupressure group (92%), while the highest rate of cesarean delivery was related to the control group (40%) and the difference was statistically significant (P < 0.001). The results showed that maternal supportive care and acupressure during labor reduced the intensity of pain and improved the delivery outcomes. Therefore, these methods can be introduced to the medical team as effective strategies for decreasing delivery pain. This trial is registered with the Iranian Registry of Clinical Trial Code IRCT2014011011706N5.

How birth doulas help clients adapt to changes in circumstances, clinical care, and client preferences during labor

This study examined how doulas adapt to challenges in client's labors. There were 104 Canadian and 92 American doulas who responded to a survey distributed at a doula conference. We report results from open-ended questions in which doulas describe how they manage changes deviating from the mother's birth plan and how they navigate differences of opinion between themselves and providers. Four themes emerged: giving nonjudgmental support, assisting informed decision making, acting as a facilitator, and issues with advocacy. Although 30% of doulas said that advocacy and information giving could result in conflict with providers, doulas reported working within their scope of practice and striving to be part of the team. Issues in doula responsibility and patient advocacy remain, and ongoing role clarification is needed.