Breast milk and labour support: lactation consultants' and doulas' strategies for navigating the medical context of maternity care

"Pills Don't Teach Skills": ADHD Coaching, Identity Work, and the Push toward the Liminal Medicalization of ADHD

Despite physicians' near monopoly over medicalization historically, various stakeholder groups shape an increasingly complex process today. This study examines a relatively new initiative, "health coaching," within the context of the changing nature of medicalization. Utilizing 51 in-depth interviews with attention deficit hyperactivity disorder (ADHD) coaches, participant observation from seven ADHD symposia, and ADHD coach publications, I examine coaching's emergence as a partial challenge to medicalization. Findings reveal a field comprised mainly of individuals personally affected by ADHD whose dissatisfaction with institutionalized framings and practices underpins a push for liminal medicalization. Members move between medical and nonmedical discourses to frame ADHD as a paradox of pathology and gift. Additionally, they leverage and commodify personal experience alongside institutional and alternative knowledge into an adjunct or substitute to medication and potential challenge to therapy-one aimed at "self-actualization" versus "treatment." Such efforts highlight (de)medicalization's dimensionality, simultaneous medicalization and demedicalization, and a lay-driven enterprise's role in such processes.

Readiness to Implement a Doula-Hospital Partnership Program

OBJECTIVE

To assess obstetric clinicians' and leaders' baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula-hospital partnership program.

DESIGN

Survey of obstetric clinicians and leaders before implementation of the doula program.

SETTING/LOCAL PROBLEM

Academic medical center in Western Massachusetts that was preparing to pilot a doula-hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality.

PARTICIPANTS

Obstetric clinicians and leaders (N = 48).

INTERVENTION/MEASUREMENTS

We used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants' knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis.

RESULTS

Forty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics.

CONCLUSION

Our findings suggested strong support for and readiness to implement the doula-hospital partnership program.

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.

Pregnancy and birth in the United States during the COVID-19 pandemic: The views of doulas

BACKGROUND

Much of the emerging research on the effects of SARS-CoV-2 disease (COVID-19) on pregnant people and their infants has been clinical, devoting little attention to how the pandemic has affected families navigating pregnancy and birth. This study examined the perspectives of doulas, or nonclinical labor support professionals, on how pregnancy and birth experiences and maternal health care delivery systems changed in the early weeks of the COVID-19 pandemic.

METHODS

Semi-structured interviews using open-ended questions were conducted over the phone with 15 birth doulas. Doulas were invited to participate because of their close relationships with pregnant and birthing people and the comprehensive support they offer. The interview transcripts were analyzed inductively.

RESULTS

Doulas' clients faced three predominant COVID-19-related pregnancy and birth challenges: (a) fear of exposure; (b) limited access to their expected support systems; and (c) uncertainties surrounding hospital restrictions on labor and birth. Doulas responded creatively to help their clients confront these challenges. Participants expressed various criticisms of how maternal health care systems handled the emerging crisis, argued that COVID-19 exposed preexisting weaknesses in US maternity care, and called for a coordinated care model involving doulas.

DISCUSSION

Doulas' close relationships with pregnant people enabled them to be an important source of support during the COVID-19 pandemic. Added to the larger body of work on the impacts of doula care, this study supports widespread calls for universally integrating doulas into maternity care systems as a targeted strategy to better support pregnant and birthing people in both crisis and noncrisis situations.

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.

Pay at the pump?: Problems with electric breast pumps

Breast pump marketing promises mothers that they will be able to follow cultural and scientific mandates to breastfeed their babies, but on their own schedules, including working outside of the home. Relatively little attention has been paid to the problems that women may experience with breast pumps. The Food and Drug Administration (FDA) regulates breast pumps as medical devices, and the agency collects data on adverse events experienced by consumers and recalls. Existing literature on breast pumps was reviewed in the contexts of medicalization and biomedicalization, and regulatory data were analyzed using mixed methods to examine the problems that women have experienced with breast pumps, which include electrical problems, suction problems, fluid leaks, injuries, and infections. While electric breast pumps promise women convenience and efficiency in pumping, women may incur personal costs, in the form of pain, injuries, and infections. These findings have implications regarding the risks of using these devices, the design of future pumps, and the future research into medical devices for reproductive and women's health.

Countervailing powers in the labor room: The doula-doctor relationship in the United States

How do health professionals with fundamentally different philosophies toward health, and different status levels, manage power in their work relationships? This paper argues that taking a negotiated order interactionist approach, which contends that the social order shapes behavior but is continuously negotiated through social interactions, and synthesizing it with a countervailing powers perspective can yield insight into the power dynamics between health professionals. It focuses on the birth field, with attention to the relationship between two very different types of birth professionals: obstetricians and doulas. Unlike doctors, who maintain a dominant place in health care and subscribe to a biomedical perspective of birth, doulas hold a low-status position and take a holistic approach toward birth, which may cause conflict in the labor room. In-depth interviews with 43 birth doulas based in the US (May-July 2018) found that the doula-doctor relationship is a complex story of power, deference, and countervailing responses. Doulas reported that doctors are more receptive to them now than in the past but that this is an outcome of creative countervailing responses involving deferential maneuvers and direct challenges to physician authority. Doulas' strategic management of their relationships with health professionals has allowed them entry to the hospital, permitting them to represent a holistic voice in the labor room. A minority of doulas have begun to develop relationships with doctors that constitute a collaborative approach toward birth care, indicating that changes in standard care are possible. By revealing how a subordinate actor can challenge physicians and effect change in care, this study contributes to scholarship seeking to understand the nature of unequal relationships between health professionals in a context of biomedical dominance.

An Integrative Review: The Role of the Doula in Breastfeeding Initiation and Duration

The objective of this integrative review was to assess birth and postpartum doulas' roles in supporting breastfeeding initiation and duration. The electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PubMed, and Scopus were searched using the key terms doula and breastfeeding. Fourteen articles met inclusion criteria. Six key themes were identified. Doulas may acquire only modest amounts of lactation-specific education; however, doula care still enhances the breastfeeding care provided by health-care professionals. Doulas offer prenatal and intrapartum support that encourages breastfeeding initiation in the hospital, as well as providing breastfeeding support in the community and home settings. This reinforces the unique role of the doula in bolstering maternal-infant health. The effect of doulas on breastfeeding duration is less clear.

Professional ambivalence among care workers: The case of doula practice

Doulas are non-medical, privately paid caregivers to women during pregnancy and childbirth, who have entered the maternity care field in recent decades. In a hospital setting, doulas offer women emotional and physical support that supplements clinical care. Drawing on focus groups and interviews with eight doulas working in one Atlantic Canadian city, along with Abbott and Merrabeau's analysis of the professionalization of 'caring' occupations, I consider how doulas navigate the uncertain terrain of their emerging occupation. In general, the work performed by care workers is viewed as an extension of the work women perform in the domestic sphere, for which they are understood to be 'naturally' talented. As a result, 'caring' occupations need to find ways to emphasize the value of their role and justify the need for adequate pay. While traditional processes of professionalization appear to offer a solution, the credentials associated with being a 'profession' - a monopoly over a field and a distinct body of (scientific) knowledge - may not be relevant when evaluating the quality of care provision. I argue that doulas hold ambivalent perspectives towards the nature of their training, the requirements of certification and 'appropriate' interactions with clients due to the broader tension between care work and professional ideology.

Hospital-based maternity care practitioners' perceptions of doulas

INTRODUCTION

A birth doula provides continuous informational, physical, and emotional support during pregnancy, labor, and immediately postpartum. Existing data on the benefits of doulas, especially for low-resource, high-need patients, do not address how and why individual practitioners decide to recommend this model of care. This project aims to describe best practices of integrating doulas into hospital-based maternity care teams to facilitate access to this evidence-based service for improving maternal health outcomes.

METHODS

Semi-structured interviews using open-ended questions were conducted in person with 47 maternity care practitioners-OB/GYNs, family medicine physicians, RNs, and nurse-midwives-across three hospitals. Interview analysis was conducted using the Template Organizing Style qualitative analysis approach.

RESULTS

Results demonstrated varied support for doula care given practitioners' experiences. Positive experiences centered on doulas' supportive role and strong relationships with patients. Some conflicts between practitioners and doulas may stem from a cross-cultural divide between mainstream obstetric/physician culture and a natural birth "counter culture." Suggestions to facilitate good working relationships centered on three overlapping themes: mutual respect between doulas and hospital staff, education about doulas' training, and clarification of roles on maternity care teams especially among staff with overlapping roles.

CONCLUSIONS

Among maternity care practitioners, some frustration, anger, and resentment persist with respect to work with doulas. Adequate staff training in the doula model of care, explicit role definition, and increasing practitioner exposure to doulas may promote effective integration of doulas into hospital maternity care 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.

Chinese News Media Discourse of Doulas and Doula Care

This article highlights the relationships among Chinese society, the discourse about doulas and doula care in childbirth, and Chinese women. The author used a critical feminist lens to analyze the discourse about doulas, doula care in childbirth, and women in Chinese mainstream news media. This analysis showed that the Chinese news media and government encouraged and promoted becoming a doula as a profession and doula care in labor in terms of cultural, social, and political factors. An argument was presented that these discourses obscure a nuanced understanding of Chinese women's maternal health in general.

Childcare workers' experiences of supporting exclusive breastfeeding in Kuala Muda District, Malaysia: a qualitative study

Background

The role of childcare workers at registered nurseries in supporting exclusive breastfeeding practice is important, as many newborn babies are placed in nurseries during working hours. To increase exclusive breastfeeding rates among working mothers, understanding childcare workers’ experiences and needs relating to supporting these mothers is crucial. This study aimed to explore childcare workers’ experiences of supporting breastfeeding at registered nurseries.

Methods

We used a qualitative design to conduct in-depth, semi-structured interviews with ten childcare workers at seven registered nursery centres in Kuala Muda District, Malaysia. Attitudes towards exclusive breastfeeding practice, experiences of breastfeeding training and information, and experiences supporting exclusive breastfeeding at the nursery were explored. Participants were asked to suggest improvements for exclusive breastfeeding practice at their nursery. All interviews were audio recorded, transcribed verbatim, and translated before analysis.

Results

All participants demonstrated a positive attitude in supporting and promoting exclusive breastfeeding practice, mainly centred on the advantages of breastfeeding. Various supports have been found such as labelling bottled breastmilk, allowing the mother to come to the nursery during breaks, and providing reading materials. However, several issues emerged that include parents’ choice on infant feeding practice, insufficient content on breastfeeding topics during training, and adherence to the (not recommended) practice of bottle feeding expressed breastmilk. Recommendations to enhance breastfeeding were also suggested by participants.

Conclusion

Childcare workers may serve as another potential resource for sustaining exclusive breastfeeding at registered nurseries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13006-016-0095-4) contains supplementary material, which is available to authorized users.

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.

Between stigma and mother-blame: blind mothers' experiences in USA hospital postnatal care

This study examines instances of discrimination that blind mothers in the USA have experienced at the hands of doctors, nurses and social workers during hospital postnatal care. The author identifies postnatal care as the time when blind mothers are likely to face the most stigmatising interactions with medical staff, as it is when scepticism about their competence as mothers is at its height. The author argues these interactions must be understood within their institutional context in which ideologies of risk and mother-blame are embedded in hospital postnatal practices.

Families, markets, and medicalization: the role of paid support for childbirth and breastfeeding

Much attention has been given to the commercialization of care and its relationship to the outsourcing of family life, as well as larger social and cultural processes that can change the nature of caring. I engage with this question of why certain aspects of care are provided by the market, using 72 interviews with lactation consultants, doulas, clients, and clinicians, as well as 150 hours of ethnographic observation in the USA. Examining how participants understood the role of these services in the maternity care system and the reasons why clients turned to these services, I found that, in several ways, these forms of care work reflected outsourcing trends. However, lactation consultants and doulas were also acting as advocates and guides, helping their clients navigate the complex medical maternity system. This reflects a fundamental transformation in the nature of maternity support, attributed to the impact of medicalization, both historically and currently.

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.

Medicalizing to demedicalize: lactation consultants and the (de)medicalization of breastfeeding

This paper uses the domain of breastfeeding in the U.S. and the work of International Board Certified Lactation Consultants to refine the concept of medicalization-demedicalization. Given lactation consultants' origins and current role in maternity care, they provide a unique lens on these processes because they are positioned at the crossroads of medicalization and demedicalization. Using 150 h of ethnographic observation and 39 interviews conducted between 2008 and 2012, I identify aspects of medicalization-demedicalization in the work of lactation consultants according to four dimensions: medical definition, medical control, pathology, and medical technology. Lactation consultants work to demedicalize breastfeeding by challenging the construction of breastfeeding pathology and limiting intervention. At the same time, they hold a position of medical control and medicalize breastfeeding by reinforcing a medical definition and using medical technology to treat breastfeeding problems. However, lactation consultants are not only working toward demedicalization and medicalization simultaneously, but are also medicalizing to demedicalize. Their position of medical control over breastfeeding provides them with a certain measure of authority that they can use in their efforts to depathologize breastfeeding and limit medical intervention. These findings build upon previous research that has identified cases of medicalization and demedicalization occurring simultaneously and draw attention to the need for an understanding of medicalization-demedicalization as a continuous process. Furthermore, the concept of "medicalizing to demedicalize" provides a novel contribution to the literature.