Defining the doula's role: fostering relational autonomy

The Implementation of a Doula Grant Program Directed at Families from Economically Vulnerable Backgrounds: A Process Evaluation

Purpose

The purpose of this study was to evaluate the process and overall feasibility of a doula grant program for expectant families from economically vulnerable backgrounds.

Design

A mixed-methods process evaluation framework was utilized to examine program feasibility and focused on constructs related to fidelity, dose delivered/dose received, reach, program satisfaction, and limited efficacy testing.

Measures

Evaluation constructs were measured using a program tracking document. Program satisfaction and efficacy were examined through a mixed methodology approach utilizing doula surveys and birthing parent interviews.

Analysis

Related to survey data, analysis focused on presenting descriptive counts and percentages related to the number of doulas that participated and clients served. Continuous variables were calculated as means and standard deviations and categorical data as counts and percentages. Qualitative data analyses were conducted using a structured deductive thematic approach.

Results

The grant program was successfully implemented over an 18-month period, and the program had a high rate of fidelity to the grant processes developed by a Midwestern-based nonprofit organization. The program was satisfactory to doulas and parents, and the largest barrier was communication. A high incidence of prenatal anxiety among the birthing parents was reported. Thematic findings from the birthing parent interviews included the following: the grant application process was effective and easy, birth doulas were greatly valued, and a financial burden was lifted.

Conclusion

This grant process can be replicated by other organizations seeking to fill a gap between doula services and the economically vulnerable.

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.

Vicarious Trauma Experienced by Health Care Providers Involved in Traumatic Childbirths: A Meta-Synthesis

Health care providers are often "second victims" of traumatic childbirth events and should be adequately supported by their organizations to alleviate occupational stress and burnout. Therefore, this review aimed to explore and understand the vicarious traumatic childbirth experiences of health care providers, including obstetricians, midwives, nurses, and students. A systematic review of qualitative studies was conducted. Seven electronic databases, namely, PubMed, CINAHL, Embase, PsycINFO, Cochrane, Scopus, and Web of Science, were searched from each database's inception to May 2020. In total, 1,575 studies were retrieved and screened according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seventeen studies were included in this review and were meta-summarized and then meta-synthesized using the Sandelowski and Barroso approach. The overarching theme of "Tunneling through the trauma with a hope of finding an end" was derived, and four main themes along with 15 subthemes were identified. The four main themes were (1) "instantaneous response to the trauma," (2) "finding hope in the midst of chaos," (3) "dealing with the aftermath," and (4) "resolution to move on." Communication and teamwork among health care team members were identified as challenges contributed by professional hierarchy and lack of role clarity. Midwives and labor and delivery nurses expressed powerlessness in advocating for women on many occasions, and health care providers often had feelings of guilt and self-blame after adverse events. Health care providers also reported inadequate support from their colleagues and organizations, which influenced their ability to cope with the aftermath of trauma and their decision to stay in the profession.

Community-based doulas for migrant and refugee women: a mixed-method systematic review and narrative synthesis

BACKGROUND

Community-based doulas share the same cultural, linguistic, ethnic backgrounds or social experiences as the women they support. Community-based doulas may be able to bridge gaps for migrant and refugee women in maternity settings in high-income countries (HICs). The aim of this review was to explore key stakeholders' perceptions and experiences of community-based doula programmes for migrant and refugee women during labour and birth in HICs, and identify factors affecting implementation and sustainability of such programmes.

METHODS

We conducted a mixed-method systematic review, searching MEDLINE, CINAHL, Web of Science, Embase and grey literature databases from inception to 20th January 2022. Primary qualitative, quantitative and mixed-methods studies focusing on stakeholders' perspectives and experiences of community-based doula support during labour and birth in any HIC and any type of health facility were eligible for inclusion. We used a narrative synthesis approach to analysis and GRADE-CERQual approach to assess confidence in qualitative findings.

RESULTS

Twelve included studies were from four countries (USA, Sweden, England and Australia). There were 26 findings categorised under three domains: (1) community-based doulas' role in increasing capacity of existing maternity services; (2) impact on migrant and refugee women's experiences and health; and (3) factors associated with implementing and sustaining a community-based doula programme.

CONCLUSION

Community-based doula programmes can provide culturally-responsive care to migrant and refugee women in HICs. These findings can inform community-based doula organisations, maternity healthcare services and policymakers. Further exploration of the factors that impact programme implementation, sustainability, strategic partnership potential and possible wider-reaching benefits is needed.

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.

Impact of Nurse-Patient Relationship on Quality of Care and Patient Autonomy in Decision-Making

BACKGROUND

The patient is observed to acquire a passive role and the nurse an expert role with a maternalistic attitude. This relationship among others determines the capacity for autonomy in the decision making of patients.

OBJECTIVES

The aim of this study is to analyse the nurse-patient relationship and explore their implications for clinical practice, the impact on quality of care, and the decision-making capacity of patients.

DESIGN

A phenomenological qualitative study was conducted.

SETTINGS AND PARTICIPANTS

Thirteen in-depth interviews with nurses and 61,484 nursing records from internal medicine and specialties departments in a general hospital from 2015-2016.

METHODS

A discourse analysis and triangulation for these sources were conducted.

RESULTS

The category elaborated from nursing records was defined according to the following codes: Good Patient, Bad patient, and Social Problem. Analysis of the interviews resulted in a category defined as Patient as a passive object.

DISCUSSION

A good nurse-patient relationship reduces the days of hospital stay and improves the quality and satisfaction of both. However, in contrast, the good relationship is conditioned by the patient's submissive role.

CONCLUSION

An equal distribution of power allows decisions about health and disease processes to be acquired by patients, autonomously, with the advice of professionals. The nurse-patient relationship should not pursue the change in values and customs of the patient, but position the professional as a witness of the experience of the health and illness process in the patient and family.

The voices of death doulas about their role in end-of-life care

'Death Doulas' have emerged as a relatively new role supporting dying people and their family members; however there is a lack of clarity around how the role is enacted, and around the death doula role within health and social care systems. This study aimed to explore the ambiguity of the role of death doulas in end-of-life care including the skills, training and experience of death doulas; how the role is communicated to the community; and the relationships to palliative care providers and other health professionals. People identifying as death doulas were invited to participate in an online survey between April and June 2018. Ethical approval was obtained. A descriptive cross-sectional study was conducted, and purposive sampling was used to survey death doulas registered with death doula training organisations, newsletters and email distribution lists. Questions were based on the researchers' previous findings about the role. One hundred and ninety completed or partially completed surveys were received. Results showed diversity within, and some commonalities across the sample in terms of: training, experience and skills; Death doulas have emerged not only as a response to the overwhelming demands on families and carers, but also demands placed on health care professionals (including palliative care) at the end-of-life. They have identified gaps in health and social care provision, perhaps taking on tasks that health professionals don't have responsibility for. However, the roles and scope of practice of death doulas is not clear-cut even within their cohort, which can then make it hard for patients and families when choosing a death doula, especially as a lack of regulation and standardised training means that doulas are working without oversight, and often in isolation.

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.

Attitudes of Physicians, Midwives, and Nurses About Doulas: A Scoping Review

INTRODUCTION

Evidence supports numerous positive clinical benefits of doula care. There are varying attitudes among physicians, midwives, and nurses toward support of doulas in a collaborative approach with women in labor. Tension and conflict with use of doulas may occur in some intrapartum settings in the United States.

METHODS

A scoping review of the literature between January 2008 and January 2018 was conducted using PubMed, CINAHL, Google Scholar, and Scopus database to identify specific attitudes of physicians, midwives, and nurses toward doulas; 1,810 records were identified and initially reviewed. Inclusion criteria included original research published in the last 10 years and in the English language. Articles were excluded if the research was not original and if obstetrical providers' or nurses' attitudes toward doulas were not included.

RESULTS

Three records met criteria for inclusion. All used a cross-sectional survey design. Two were set in Canada exclusively and one was inclusive of nurses and doulas in both Canada and the United States. Themes emerged that may explain the influence and variances in attitudes toward doulas and the support they provide to laboring women.

CLINICAL IMPLICATIONS

More research is needed to identify attitudes of members of the maternity care team toward doulas and to better understand implications of their attitudes on working together collaboratively and on patient outcomes.

An interprofessional approach to prevent recurrent obstetric anal sphincter injury (OASIS): A case report

Successful outcomes in this case are consistent with the American College of Obstetricians and Gynecologist (ACOG) guidelines for preventing OASIS. The interprofessional birth care team (IBCT) model exemplified by this case focuses on best practice in promoting a family's preferences for physiologic birth and preventing recurrent OASIS.

Relational autonomy in breast diseases care: a qualitative study of contextual and social conditions of patients' capacity for decision-making

BACKGROUND

A relational approach to autonomy refers to the way in which social conditions and relationships shape a person's self-identity and capacity in decision-making. This article provides an empirical account of how treatment choices for women undergoing breast diseases care are fostered within the dynamics of their relationships with clinicians, family members, and other aspects of their social environment.

METHODS

This qualitative study recruited ten women undergoing treatment at a breast programme, and eight clinicians supporting their care, in a private teaching hospital in New South Wales, Australia. Fourteen patient-clinician consultation observations and 17 semi-structured interviews were conducted. Schema analysis of interview transcripts were undertaken by a team of researchers and corroborated by observational fieldnotes.

RESULTS

Relational identities of patients influenced the rationale for treatment decision-making. Patients drew on supportive resources from family and medical advice from clinicians to progress with treatment goals. While clinicians held much social power over patients as the medical experts, patients highlighted the need for clinicians to earn their trust through demonstrated professionalism. Information exchange created a communicative space for clinicians and patients to negotiate shared values, promoting greater patient ownership of treatment decisions. As treatment progressed, patients' personal experiences of illness and treatment became a source of self-reflection, with a transformative impact on self-confidence and assertiveness.

CONCLUSION

Patients' confidence and self-trust can be fostered by opportunities for communicative engagement and self-reflection over the course of treatment in breast disease, and better integration of their self-identity and social values in treatment decisions.

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.

'The greatest feeling you get, knowing you have made a big difference': survey findings on the motivation and experiences of trained volunteer doulas in England

BACKGROUND

Support from a doula is known to have physical and emotional benefits for mothers, but there is little evidence about the experiences of volunteer doulas. This research aimed to understand the motivation and experiences of volunteer doulas who have been trained to support women during pregnancy, birth and the postnatal period.

METHODS

A postal questionnaire survey was sent to volunteer doulas at five volunteer doula projects working in low-income areas in England. Quantitative and qualitative data were analysed in parallel using summary statistics and content analysis respectively.

RESULTS

Eighty-nine volunteer doulas (response rate 34.5 %) from diverse backgrounds responded to the survey. Major motivators for volunteering included a desire to help others and, to a lesser extent, factors related to future employment. Most reported that the training was effective preparation for their role. They continued volunteering because they derived satisfaction from the doula role, and valued its social aspects. Their confidence, skills, employability and social connectedness had all increased, but many found the ending of the doula-mother relationship challenging. For a minority, negative aspects of their experience included time waiting to be allocated women to support and dissatisfaction with the way the doula service was run.

DISCUSSION AND CONCLUSIONS

Most respondents found the experience rewarding. To maintain doulas' motivation as volunteers, services should: ensure doulas can start supporting women as soon as possible after completing the training; consider the merits of more flexible endings to the support relationship; offer opportunities for ongoing mutual support with other doulas, and ensure active support from service staff for volunteers.